Please select one:
c Recurring Draft (no installment fees)
Preferred method of receiving direct draft billing statement:
c Email to:
c Fax to:
®
Please return the completed form to:
BHGIC Accounting Services | P.O. Box AH | Wilkes-Barre, PA 18703-0020 csr@guard.com 570-820-7968
Policyholder Name: Policy #:
Policy #: Policy #:
Bank Name:
Name on Bank Account:
Bank Account #: Bank Routing #:
Optional: Attach a voided check to assist us in verifying your account information.
Agreement: By signing below, you are enrolling in Berkshire Hathaway GUARD’s Direct Draft Program
®
, authorizing West-
GUARD
®
Insurance Company, holding company for AmGUARD Insurance Company
®
, NorGUARD Insurance Company
®
, and
EastGUARD Insurance Company
®
members of Berkshire Hathaway GUARD Insurance Companies (“GUARD”) with principal
place of business at 39 Public Square, Wilkes-Barre, PA 18701 to disclose this document to the cited bank and to initiate an
electronic transfer of funds from the bank account cited to pay the insurance premiums for the indicated policy(ies), and any
renewals thereof, in accordance with either the one-time draft amount cited or per the payment terms of your insurance poli-
cy(ies). Any overpayment or refunds of premiums may be returned to the bank account cited. Attempted withdrawals encoun-
tering insucient funds or a closed account may be assessed a fee up to $20 (depending upon the state and subject to change
with or without notice). Premiums may change in accordance with the terms and conditions of the policy or contract. If you
are not the owner of any policy or contract identied above, you will not receive advance notice of any change in the amount
of any authorized withdrawal with respect to such policy or contract. The owner of the policy or contract is responsible for en-
suring that adequate premiums are paid to keep the policy/contract in force, even if the direct draft does not occur as sched-
uled or the amount drafted is insucient. This authorization remains in effect until you notify GUARD otherwise in writing.
Authorized Signature:
Date Signed:
Printed Name: Phone #:
c One-Time Draft
Amount: $
Not an available option for policyholders on self-
reporting payment plans. One-time direct drafts will
be charged an installment fee up to $7 in select states.
FLDD110220
Direct Draft Program
®
Authorization Form
Direct Draft Program
®
PAYMENT OPTIONS
