†
Only Genworth Life Insurance Company of New York is admitted in and conducts business in New York.
Genworth Life & Annuity
Genworth Life
Genworth Insurance Company
Genworth Life of New York
P. O. Box 40016
Lynchburg, Virginia 24506-4016
Tel: 888 GENWORTH (436.9678)
Fax: 877 300.1280
GNWEFTForms@genworth.com
Electronic Funds Transfer (EFT) Authorization
for Renewal Premiums
from Genworth Life and Annuity Insurance Company,
Genworth Life Insurance Company, Genworth Insurance Company
and
Genworth Life Insurance Company of New York
†
Page 1 of 1
• All fields on the form must be completed prior to submitting the request.
EFTAuthS-PHS 09/27/18
Policy number
▪
Insured name(s) Date of birth
▪ ▪
Policy information
Premium payments
Use this section to select your
payment frequency for your
scheduled premium withdrawals.
If no selection is made,
withdrawals will be monthly.
○
Monthly*
○
Quarterly
○
Semi-Annually
○
Annually
*We may initially draft two payments to make sure your coverage is up to date.
For most products, there is an additional cost if you pay premiums more often than annually.
Payment amount authorized (if other than scheduled premium amount)
$
Bank account information
A voided check MUST be
included with your request in
order for it to be processed.
Address information is essential
for communications with the
bank account owner regarding
future drafts.
Deposit slips are not acceptable.
Bank account owner name(s)
▪
Bank account owner address
▪
▪
Financial Institution Name
▪
Routing number
▪
Checking account number
▪
I
¦
For checks with an ACH RT (Automated Clearing House
Routing) number, please use this number.
For all other checks, use the nine-character bank routing
number, which appears between the symbols, usually
at the bottom left corner of the check.
I
¦
The account number is up to 17 characters long and appears
next to the symbol at the bottom of the check and usually
to the right of the bank routing number.
II
John Henry Doe
PH. 000-000-0000
1234 Any Street
Mycity, VA 00000
Authorization
By signing this form, I (the bank
account owner) understand and
accept these terms and
conditions:
• You will withdraw the scheduled premium payments from my account
• You will only consider a premium paid if a draft is honored by my financial institution
• You may discontinue withdrawals at any time and bill me directly
• I have 60 days from the date of the withdrawal to notify you of any errors related to a transfer
under this agreement, including unauthorized transfers. If I fail to notify you within 60 days,
I am liable for any transfers that occur after close of 60 days.
• I must contact you at least three business days before a scheduled withdrawal to change or cancel
this authorization
Signature of bank account owner Date
X ▪
