8069 LTC (082018)
Use this form to start a new bank draft/ACH arrangement or change an existing one.
STEP 1 Tell us your contact information.
Policy owner name (First, M.I., Last) Corporate/Trust name
Daytime phone
Email
Address
Check if new
STREET
APT.
CITY
STATE
ZIP
STEP 2 Tell us your policy number(s). Please only list policies where you are the insured or owner.
Insured name
Premium amount
Need assistance?
If you have any questions
or concerns, we’re here to
helpjust call us at
(800) 224-4582
Monday through Friday
8:00AM-6:00PM CST.
$
$
$
$
STEP 3A Tell us what bank account you’d like to use—funds are withdrawn as individual transactions each month.
Routing
number
Bank name
Account number
Checking
Savings
Name of account holder
STEP 3B Please only complete if the bank account holder named above (the payer) is not the insured or owner.
Helpful tip: provide the designated payer’s information below and indicate the payer type in the signature section on the next page.
Social Security or Tax ID number
Date of birth
Relationship to insured or owner
MONTH
DAY
YEAR
Address
No PO boxes
please
STREET
APT.
CITY
STATE
ZIP
STEP 4A Read and sign.
By signing I authorize New York Life Insurance Company, or any of its subsidiaries specified in that Application (collectively,
“New York Life”), to pay policy premiums by withdrawing them from the account listed in Step 3 above and to make refunds
to that account. I also authorize the bank associated with that account to debit and/or credit that account accordingly.
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8069 LTC (082018)
STEP 4A Read and sign (continued from previous page).
I understand that if I authorized subsequent premium payments that the withdrawals will normally be debited monthly on a
regular schedule established by New York Life. This arrangement does not change the premium due date specified in the
policy and will not extend any applicable grace or late periods for premium payment; the policy will lapse at the end of any
applicable grace or late periods if the premium remains unpaid; I will not receive premium notices while this arrangement is
in effect.
I also understand that I (or the policy owner) may terminate or modify this arrangement at any time by notifying New York
Life at least 10 days prior to the withdrawal date. Such notifications must be made by calling us at (800) 224-4582, or
sending a signed and dated request that must include the last 4 of your SSN and policy number, to the address on this
form.
Your signature(s) confirm(s) that you have read all the information on this form and that the information you have provided is correct.
X
Policy owner signature
(Required)
Name (Print)
Last 4 of SSN
(Required)
Date
STEP 4B Please only complete if you are a designated payer.
If the owner or payer is a corporation or trust, please provide signatures of two corporate officers or required trustees
other than the insured. Titles are required.
Payer Type If you are one of these designated payer types, please check
the appropriate box and sign below.
Corporation
Trust
X
Bank account owner signature
(Required if other than insured or owner)
Name (Print)
Title
Date
X
Bank account owner signature
(Required if other than the insured or owner)
Name (Print)
Title
Date
STEP 5 Done! Send us your completed form.
You have options. Pick one that best suits your needs.
By mail:
By email:
By fax:
New York Life, Long-Term Care Insurance, PO Box 64670, St. Paul, MN 55164-0670
NYLPolicyAdmin@ltcg.com
(866) 294-7031
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