Fillable PRE-AUTHORIZED WITHDRAWAL AGREEMENT Policy Number Name of Insured

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PRE-AUTHORIZED WITHDRAWAL AGREEMENT Policy Number Name of Insured

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SVC-117-PL Pre-Authorized Withdrawal Agreement 11/2017
Protective Life Insurance Company
Life and Health Insurance Administration
P.O. Box 12687
Birmingham, AL 35202-6687
PRE-AUTHORIZED WITHDRAWAL AGREEMENT
FOR DRAFTING OF PREMIUM PAYMENTS
The person payi
ng the premium on the insurance policies listed below must sign this agreement.
I request and authorize Protective Life Insurance Company to draw against the account listed below to
pay premiums on the following policies:
Policy Number Name of Insured Name of Policy Owner
Name of Bank: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Street Address or P.O. Box: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
City: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
State: |___|___| Zip Code: |___|___|___|___|___| — |___|___|___|___|
Type of Account: Checking Savings
Routing Number: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Account Number: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Premium Frequency (Please check one.): Monthly Quarterly Semi-Annually Annually
I would like the date of the withdrawal to occur on the _________________ (Please indicate the
date(s) or 1
st
– 28
th
for monthly payments.).
_____________________________________________
Premium Payor – Depositor (Please Print)
Please complete your name and email address if
you would like us to send you draft confirmations.
Your Name: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
Email Address: |___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|___|
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the location of Routing and
A
ccount numbers.
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PRE-AUTHORIZED WITHDRAWAL AGREEMENT Policy Number Name of Insured

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Completed 28 October 2021

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