Recurring Credit Card Authorization Form
Form to be used for the collection of
Recurring Credit Card information on authorized plans.
Please read this authorization carefully and complete all requested items.
Policy Number: ________________________________________________________________________________________
Name of Proposed Insured: ______________________________________________________________________________
Proposed Policy Owner: ________________________________________________________________________________
E-mail Address: ________________________________________________________________________________________
(Note: A valid e-mail address is necessary in order for us to notify you of your recurring credit card set up, charges, and declines. Without
a valid e-mail address, we will not be able to set up your recurring credit card request at this time. Should you not have an e-mail address
we will need to ask that you select a different method of payment.)
Cardholder Name (exactly as it appears on the card): ______________________________________________________
Social Security Number: ________________________________________________________________________________
Cardholder Billing Address: ____________________________________________________________________________
________________________________________________________________________________________________________
Credit Card Number: ____________________________________________ Expiration Date: ______________________
Card Type: American Express
®
MasterCard
®
Visa
®
Premium Amount: ______________________________________________
Payment frequency of ongoing premium payments:
Annual Semi-annual Quarterly Monthly
____________________________________________________________________________________________________________
By signing below, I, ______________________________________, authorize American General Life Insurance Company
or The United States Life Insurance Company in the City of New York (the ‘’Company’’) or its representative to charge
my debit/credit card for the amount indicated above on a recurring basis as premiums become due.
I understand and agree that this transaction is subject to the acceptance by, and the terms and conditions of, the
credit card company/bank indicated. I also understand this Authorization is not a part of the policy/contract of
insurance, and that if premiums are not paid within the applicable grace period, the coverage will lapse. I further
understand and agree that the Company shall incur no liability if the bank/credit card company dishonors any amount
charged under this Authorization. I also agree that this Authorization may be terminated at any time and for any
reason by either myself or the Company upon notice to the other party. Upon termination of this Authorization, the
Company will bill me directly for any premium amount due.
I understand that I will be provided with confirmation of the recurring charge amount ; however, the initial charge
to my account will include all currently due and past due premiums.
Signature of Authorized Person on Account:
X ______________________________________________________________________ Date: ________________________
AGLC106248-GIWL
