PRE-AUTHORIZED CHEQUE PAYMENT (“PAC”)
AGREEMENT/CHANGE
Sales network compensation
iA Financial Group is a business name and trademark of
Industrial Alliance Insurance and Financial Services Inc.
ia.ca
F12-197A
F12-197A(20-05)
PRE-AUTHORIZED CHEQUE PAYMENT (“PAC”) AGREEMENT/CHANGE
In this PAC Agreement, each owner is referred to as “I” and makes the following statements in respect to himself or herself:
• I authorize Industrial Alliance Insurance and Financial Services Inc. (the “Company”) and the financial institution designated (or any other financial institution I may authorize
at any time) to begin deductions as per my instructions for regular recurring payments and/or one-time payments from time to time for payment of all deposits and charges
arising from the contract mentioned herein;
• Regular payments will be debited by the date and/or frequency I have chosen, whereas one-time payments from time to time can be debited from my account on any date.
Regular and/or one-time payments will be debited in accordance with the banking information set out below;
•
I agree that, for the purpose of this PAC Agreement, all PACs from my account will be treated either as Personal or Business* depending on the choice I have made below;
•
I waive the right to receive pre-notification of an increase or decrease in the amount to be debited or a change in the date and/or frequency of these payments;
•
I agree that the Company is not required to provide me with written notice of a change in a PAC amount that is made as a result of my request;
•
If a PAC is dishonored for any reason such as, but not limited to, insufficient funds (“NSF”), stop payment or account closed, the Company is authorized to re-submit the payment.
Any charges incurred by the Company as a result of a dishonored PAC will be charged in the account;
•
I may cancel or modify this PAC Agreement at any time, subject to providing the Company thirty (30) days notice in writing. To obtain a sample cancellation form or for more
information on my right to cancel the PAC Agreement, I may contact my financial institution or visit www.cdnpay.ca regarding Rule H1-Pre-authorized debits (PADs);
•
Any cancellation of this PAC agreement will not affect my contract(s) in any way;
• The Company will not assign this PAC/EFT Agreement without providing, any time prior to the next PAC/EFT, written notice to me of the assignment;
•
I have
certain recourse rights if any PAC does not comply with this PAC Agreement. For example, I have the right to receive reimbursement for any PAC that is not authorized
or is not consistent with this PAC Agreement. To obtain more information on my recourse rights, I should contact my financial institution or visit www.cdnpay.ca regarding
Rule
H1-Pre-authorized debits (PADs);
•
Before the Company debits the first PAC payment, it must receive all required documents, duly completed, and be allowed a reasonable period of time to complete its
administrative processes.
* Business PAC means a PAC for the payment of goods or services related to a business or commercial activity of the payor.
GENERAL INFORMATION
1. Indicate if it’s a: Regular PAC enrolment. (Complete items 2 and 3.)
!
Signature mandatory Resume PAC.
New banking information. (Staple a void, personalized cheque.)
!
Signature mandatory
PAC modification (Signature not required) for PAC type: Regular Reimbursement
Terminate the PAC on
Y Y Y Y M M D D
(Signature not required)
2. Banking information
• Staple a blank, personalized cheque marked “VOID” or enclose a duly completed written confirmation from the financial institution; OR
• Supply the requested banking information below.
!
If you attach a “VOID” cheque, do not fill out the bank information below.
Financial institution name: ��������������������������������������������������������������������������������������������������������������������
Name of the account owner(s): ��������������������������������������������������������������������������������������������������������������
Account number Transit Number Financial Institution Number
(max. 12 digits) (5 digits) (3 digits)
3. Withdrawal Agreement: Variable PAC Category: Personal Business (If both boxes are left unchecked, the PAC category will deemed to be “Personal”.)
Amount of PAC: $������������������������
Frequency: Weekly Monthly (no monthly withdrawal from the 29th to the 31st of each month)
Every two (2) weeks; Day: ���������������� (Monday to Friday)
One-time payment: $��������������
Starting on:
Y Y Y Y M M D D
SIGNATURE
!
Mandatory for enrolment and new banking information, all required signatories must sign this PAC/EFT Agreement. For a company, the PAC
Agreement must be signed by an authorized signatory; attach a copy of the company’s resolution stipulating the authorized signatories.
���������������������������������� X��������������������������������������������� X���������������������������������������������
Date Account owner’s signature (as shown on bank records) Second account owner’s signature (if applicable)
Contact Information:
Quebec : Industrial Alliance Insurance and Financial Services Inc., Sales Network Compensation (IRA 2543)
1080 Grande Allée West, PO Box 1907, Station Terminus, Quebec City, QC G1K 7M3
Agency code Agent code Agent Agent’s telephone number
