Electronic Funds Transfer (EFT) Authorization For
Direct Payments (ACH)
(For use with New Business only – NOT Inforce policies)
Mail or fax completed form to:
P.O. Box 305030, Nashville, TN 37230-5030
Fax: 800 262 6976 Attn: New Business
Contact us:
Customer Contact Center – Tel: 855 887 4487
Accordia Life and Annuity Company
Des Moines, IA
20057 (08-19)
DRAFT OPTION
(check all that apply)
INITIAL DRAFT OF PREMIUM: Authorization to draft initial premium IMMEDIATELY
Upon the receipt of this form, please process a draft for the initial premium in the amount of $
for the applicant name shown below. I am aware the draft will be processed within 48 hours of receipt of this
request.
(If not opting for initial draft, please pay the initial premium by check or wire transfer.)
ONGOING DRAFT OF PREMIUM: Please deduct future premiums in the amount of $
_______________ (1
st
– 28
th
)
of the month they are due.
Please deduct future subsequent premiums: Monthly Quarterly Semi-Annually Annually
By selecting this option, you are authorizing subsequent renewal premiums to be deducted from the account listed below
on the day of the month requested according to the mode selected.
AUTHORIZATION TO HONOR DEDUCTIONS DRAWN BY ACCORDIA LIFE AND ANNUITY COMPANY
I hereby request and authorize Accordia Life and Annuity Company
(“Accordia”)
to honor and charge the account listed below,
deductions drawn on my account by and payable to Accordia. This authorization will remain in effect until a written revocation
is received by Accordia from the account holder. Accordia shall be afforded 30 days to act upon such revocation and until such
time has expired, any electronic fund transfers shall be expressly authorized. Accordia may cease acknowledging my
authorization at any time for any reason so long as written notice is provided to the account holder 30 days prior to the
effective date of such revocation.
I further agree if such deduction drawn from my account is dishonored, whether with or without cause, Accordia shall have no
liability, even though such dishonor may result in the forfeiture of insurance. In the event a deduction drawn from the account
is dishonored, I understand Accordia may terminate this authorization without notice. I understand completion of this form
DOES NOT provide coverage under a Conditional Life Insurance Agreement.
PROPOSED INSURED INFORMATION
Date of Birth
(mm/dd/yyyy)
Social Security #
(last 4 digits)
XXX – XX -
Account Holder Name
(if different than insured)
Financial Institution/Bank Name
Financial Institution/Bank – City/State
Routing Number
(Bottom left of check)
Account Number
(Bottom right of check)
A voided/blank check accompanying this form is preferred, but not required.
click to sign
signature
click to edit
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