Fillable PROTECTIVE LIFE INSURANCE COMPANY

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PROTECTIVE LIFE INSURANCE COMPANY

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The person paying the premium on the life insurance policy listed below must sign this agreement.
Type of Account: Checking
Routing Number:
Account Number:
Premium Frequency: *Monthly (*Only available by bank draft) Quarterly
Semi-Annually Annually
V
ariable life insurance premiums will not be deducted unless a policy is issued.
Premium Payer - Depositor (Please Print)
Date Signature
PL-104
Draft the initial premium - I understand that authorizing the drafting of the initial premium and providing the
account information does not provide any life insurance coverage on myself or any applicant listed on the
application for life insurance unless I have signed, dated and met the terms and conditions of the Protective Life
Conditional Receipt Agreement/Temporary Life Insurance Receipt.
If the Company receives a Conditional/Temporary Receipt with this form your premium will be drafted
immediately and you will be provided with conditional coverage subject to limited terms and conditions.
I request future drafts be made on the ______________ (1st - 28th) day of the month.
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06/14
Policy Number: ____________________________
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Name of Insured: _____________________________________
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Name of Bank: ___________________________________________________________________________________
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Street Address or P.O. Box: _________________________________________________________________________
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City: _________________________________ State: ______________________ Zip Code: ____________________
PRE-AUTHORIZED WITHDRAWAL AGREEMENT
FOR DRAFTING OF PREMIUM PAYMENTS
I request and authorize Protective Life Insurance Company to draw against the account listed below to pay premiums. I
understand that no coverage exists until a policy is issued or I receive a Conditional Receipt/Temporary Life Insurance
Receipt.
Savings
PLEASE INCLUDE A VOIDED CHECK WITH APPLICATION. IF THIS IS TO DRAFT FROM A BROKERAGE
ACCOUNT, A VOIDED CHECK IS NOT NECESSARY. DO NOT USE STAPLES.
PROTECTIVE LIFE INSURANCE COMPANY
P.O. Box 830619
Birmingham, AL 35
283-0619
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PROTECTIVE LIFE INSURANCE COMPANY

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Completed 13 December 2021

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