Farm Bureau Life Insurance Company
5400 University Avenue
West Des Moines, Iowa 50266-5997
AUTOMATIC DEPOSIT
AUTHORIZATION
AGREEMENT
I hereby authorize Farm Bureau Life Insurance Company and its Affiliates (collectively, “Farm Bureau”) to make
deposits to my account and for the Financial Institution named below to accept those deposits. I also authorize
Farm Bureau to make withdrawals from my account if necessary, to correct an incorrect deposit amount and for
the Financial Institution to accept such withdrawals.
Farm Bureau will complete Account Number and ABA Transit Numbers from the voided check attached below.
This authority is to remain in full force until Farm Bureau receives written notification from me of its termination
in such time and in such manner as to afford Farm Bureau a reasonable opportunity to act on it.
Owner Name:
Payee/Annuitant:
Contract/Policy #:
Date:
(Signature of Bank Account Owner(s)
Date:
(Signature of Bank Account Owner(s)
Account Information: Checking Savings
Financial Institution Name:
Address:
City, State:
Financial Institution Transit/ABA #:
Account #:
PLEASE ATTACH VOIDED CHECK HERE
Note: If a voided check cannot be supplied please submit a current bank statement that lists
the bank account owners and bank account number. A letter from the bank, signed by a bank
officer, verifying the same information is also acceptable. A deposit slip or starter check will
not be accepted
.
433-191(11-19) Page 1 of 1
