Americo Financial Life and Annuity Insurance Company • Home Office: Dallas, Texas • Administrative Office: PO BOX 410288, Kansas City, MO 64141-0288 • www.americo.com
AF55019 (11/18)
Americo Financial Life and Annuity Insurance Company
Phone: 800.231.0801 • Fax: 800.395.9238 • Email: forms@americo.com
DRAFT INFORMATION
As a convenience to me, I hereby request and authorize the banking institution below (the “Bank”) to pay
and charge to my account drafts on my
account by and payable to the order of the company who issued or assumed the policy listed below (the “Company”) administering my insurance policy
provided there are sufficient collected funds in said account to pay the same upon presentation. I agree that the Bank’s rights in respect to such draft
shall be the same as if it were a check drawn on the bank and signed personally by me. This authorization will remain in effect until revoked by me
or the Company. Notifications should be sent to PO BOX 410288, Kansas City, MO 64141-0288, Attention Customer Service. Our toll-free
number is 800.231.0801. I agree that the Bank shall be fully protected in honoring any such draft. I further agree that if any such draft be dishonored,
whether with or without cause and whether intentionally or inadvertently, the Bank shall be under no liability whatsoever. Should any draft not be
honored by the Bank upon presentation, I understand that this method of payment may be terminated. I further understand that should any draft not
be honored for the reason of “insufficient funds”, a second attempt to draft may occur within 5 business days from the returned draft date.
I understand that Americo requires a 5 business day advance notice to set up, change, or discontinue my bank draft information. I also
understand that my insurance policy may lapse if said draft is returned unpaid by my Bank, or if I discontinue payments, prior to receiving confirmation
of draft processing from the Company. Please keep a copy of this authorization with your banking records.
FOR EXISTING POLICIES: Unless otherwise requested, premium draft date will be the existing premium due date.
DRAFT DATE: (If no option is selected, Draft Date will default to the first option listed below)
Upon issue and on the policy’s regular due date thereafter
Specific start date: __________ / __________ (must be within 10 days of the Due Date and cannot be on the 29
th
, 30
th
, or 31
st
of the month.
Month Day It may take up to 4 business days from the day we initiate the draft for your bank to process
this transaction.)
Additional option for Final Expense applications (Also available for in-force policy numbers starting with “AM” issued after December 2011.)
Day of week: ____________ / _____________ (Draft day must be specified using Monday through Example: Second / Monday
Week of Month Day of Week Friday for a specific week of the month (First-Fourth). Week of Month Day of Week
The actual date of draft could vary each month.)
(If no option is selected, Account Type will default to the checking account option)
Checking Account (attach voided check)
Savings Account (attach deposit slip)
Check with Application (use the deposit and routing numbers from the enclosed check in lieu of a voided check)
Please use Bank Draft information from Americo policy number:________________________________________________
INSURED
INFORMATION
Insured Name(s) Policy Number(s)
PAYOR
INFORMATION
Relationship to Proposed Insured
(If mailing address is a PO Box, a
street address is also required)
How long at current address? ___________ If less than 5 years at current address, prior address required.
SIGNATURE
________________________________________________________ ________________________________
Payor’s Signature (REQUIRED, as it appears on bank records) Date
Complete below only when voided check or deposit slip is not available
ALTERNATE
ACCOUNT VERIFICATION
Routing Number
Account Number
Check here if this is a business account
Agent’s Certification (For New Business only)
I do hereby attest that I personally verified this information. I understand that any misrepresentation or falsification on my part will rescind my
privilege to use this form and may lead to immediate termination of my appointment with the Company.
_________________________________________________________________ _______________________
Agent’s Signature (REQUIRED) Agent’s Number
Bank Draft
AF55019 (11/18)
