Fillable AUTHORIZATION FOR PRE-AUTHORIZED DEBITS (PADs) AND CREDIT CARD

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AUTHORIZATION FOR PRE-AUTHORIZED DEBITS (PADs) AND CREDIT CARD

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AUTHORIZATION FOR PRE-AUTHORIZED DEBITS (PADs)

AND CREDIT CARD PAYMENTS

I/WeauthorizeSASKATCHEWANMUTUALINSURANCECOMPANY(SMI)tomakeautomaticdeductionsfrommy/ourbankaccount/creditcardaspermy/ourinstructionsforregularrecurring

paymentsand/orone‐timepaymentsfromtimetotime,forpaymentofinsurancepremiumandanyapplicablecharges.AllamountswillbeinCanadianfunds.

Withdrawals/chargesmaybeforvariab

leamounts,astheymaychangeinaccordancewithmy/ourinsurancecontractandasrequiredtoadministermy/ourpolicy.

I/Wewaivetherighttoreceivefurthernoticeoftheamountanddateofeachautomaticwithdrawalfrommy/ouraccount.

I/Wewillensurefundsareavailableoneachduedateandunderstandthatnon‐sufficientfunds/declinedpaymenttransactionsmayresultinoneorallofthefollowing:1.Asecondpresentation

orattempttowithdrawfundswithin30days2.Cancellationofmy/ourpaymentplanagreement.3.Cancellationofmy/ourpolicy.

I/Weun

derstandthisauthorizationmaybecancell

edbyme/usuponnoticewithin10(ten)businessdaysbeforethenextscheduledpremiumwithdrawal.I/Weunderstandthisauthorization

iscontinuousandwillautomaticallyapplytotherenewaltermsuntilSMIhasreceivednotificationfromme/usofitschangeortermination.I/Wemayobtainasamplecancellationform,or

moreinformationonmy/ourrighttocancelaPADAgreementatmy/ourfinancialinstitutionorbyvisitingwww.cdnpay.ca.

I/WeauthorizeSMItocollectorusemy/ourpersonalinformationforthepurposeofthisauthorizationforautomaticwithdrawalsforpaymentsofmy/ourinsurancepremiums.I/Weauthorize

SMItodiscloseanypersonalinformationcontainedinthisauthorizationformtoitsfinancialinstitutiontotheextentdisclosureisdirectlyrelatedto,andnecessary,fortheproperexecutionof

thepr

e‐authorizeddebittransactionforpaymentofpremiumsdirectlyrelatedtomy/ourinsurancepolicy.

I/Wewarrantandguaranteethatallpersonswhosesign

aturesarerequiredtosignonthisaccounthavesignedthisauthorization.

Please complete authorization information below. Incomplete forms will be r

eturned.

1. PolicyInformation:

NameofInsured/CompanyName TypeofInsurancePolicy

Personal Business

SMIPolicyNo.

Address(street,city,province) Postalcode TelephoneNo.

2. PaymentPlan:

(Paymentswillbeprocessedontheselectedintervalbasedontheeffectivedateofthepolicy)

Monthly Tri‐Annual Semi‐Annual Annual

One‐TimePayment(nofuturepaymentstobeprocessedwithoutauthorization):

SinglePaymentOnly:$____________pleaseinvoiceme/us: Tri‐Annual Semi‐Annual Annual

PaymentMethod:

PreauthorizedDebit:(Pleaseattacha“Void”Cheque)

I/Wehavecertainrecourserightsifanydebitdoesnotcomplywiththisagreement.Forexample,I/wehavetherighttoreceivereimbursementforanyPADthatisnotauthorizedor

isnotconsistentwiththisPADAgreement.ToobtainaformforaReimbursementClaimorformoreinformationonmy/ourrecourserights,I/wemaycontactmy/ourfinancial

institutionorvisitwww.cdnpay.ca.

NameandLocationofFinancialInstitution InstitutionNo. TransitNo. AccountNo.

CreditCardPayment:

InconsiderationforSMIpermittingpremiumpaymenttobefinancedthroughVISAorMasterCard,itisherebyunderstoodthatSMImaycreditmy/ourVISAorMasterCardaccount

foranyreturnpremium.Maximumannualpolicypremiummustnotexceed$15,000.

CreditCardType

Visa Mastercard

CreditCardNumber

__ __ __ __\ __ __ __ __\ __ __ __ __ \ __ __ __ __

ExpirationDate(MM/YY)

__ __\ __ __

4. BillingInformation:(Ifdifferentfromabove)

Account/CardHolder‐Lastandfirstname(s) TelephoneNo.

Address(street,city,province) Postalcode

AuthorizedSignature:_______________________________________________ Date:______________________

DD/MMM/YYYY

(Ifapplicable)

AuthorizedSignature:_______________________________________________ Date:______________________

DD/MMM/YYYY

Mailorfaxcompletedformto:SaskatchewanMutualInsuranceCompany–2793rdAvenueN,Saskatoon,SKS7K2H8

Tel:1‐800‐667‐3067;Fax:1‐888‐353‐3293;Email:accounting@saskmutual.com

C56 (03/17)

CSVNumber

__ __

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AUTHORIZATION FOR PRE-AUTHORIZED DEBITS (PADs) AND CREDIT CARD

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Completed 6 January 2022

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