PRE-AUTHORIZED CHECK/WITHDRAWAL PLAN (“PAC”)
POLICY NO. INSURED AMOUNT
MONTHLY (This will be elected if no box is checked)
QUARTERLY
SEMI-ANNUAL
ANNUAL
PREMIUM
LOAN REPAY
SAVINGS
CHECKING
NEW AUTHORIZATION
BANK CHANGE
ADD TO EXISTING POLICY
OTHER
NAME OF FINANCIAL INSTITUTION:
PHONE #:
ADDRESS:
CITY, STATE, ZIP:
ACCOUNT NUMBER:
NAME(S) ON BANK ACCOUNT:
ROUTING#:
I request and authorize Transamerica Life Insurance Company (the Company) to make withdrawals, by draft or electronic transfer, from my account with the Financial
Institution named above for premiums in the amounts specifi ed above, or as specifi ed by the policy (including any amendments, endorsements or riders), or as agreed
to by me, and for such other payments as I may authorize the Company to make. I request that the withdrawal be on or before the days when payment(s) fall due, except
that if a withdrawal is to pay for premiums on more than one policy, it is to be drawn on the earliest due date. I request that this authorization, unless previously revoked,
continue to apply to any conversion, renewal, or change later made in the policies. I understand that this authorization in no way affects the terms of the policy, other than
the mode of payment, and I understand that if the premiums are not paid within the grace period allowed by a policy, as in the event any such withdrawal being dishonored, or
for any reason, then the policy shall terminate subject to any nonforfeiture provisions in the policy.
AUTHORIZATION FOR PARTICIPATION IN THE PAC PROGRAM
AUTHORIZATION TO HONOR PAC WITHDRAWALS
As a convenience to me, I hereby request the fi nancial institution named above to accept and honor the draft or transfer withdrawals from my account. I agree that your rights
in respect to each draft or transfer shall be the same as if it were a check drawn on you and signed personally by me and that you shall be fully protected in honoring such draft
or transfer. I further agree that if any such withdrawal is dishonored, whether with or without cause and whether intentionally or inadvertently, the Financial Institution shall be
under no liability whatsoever if such dishonor results in the forfeiture of insurance.
These authorizations shall remain in effect until revoked in writing, mailed to the other parties at the address of record. The Company and/or Financial Institution shall
have a reasonable time to act on the revocation notice. I have retained a copy of these authorizations.
BANK SIGNATURE(S) OF DEPOSITOR(S) SIGNATURE OF POLICYOWNER IF NOT DEPOSITORDATE
TAPE VOIDED CHECK HERE
PAC10609T TG-NF
Unless a Conditional Receipt was issued along with this authorization, I/we agree this authorization shall not become effective for payment of the initial
premium unless and until after a contract is issued and all other conditions of coverage set forth in Part 1 of the application have been met.
PICK A DATE TO DRAFT (1-28)
*DT084*
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