AUTHORIZATION AGREEMENT FOR ACH DEBITS AND CREDITS



ELECTRONIC FUNDING

AUTHORIZATION

|Policyholder Name |      |

We hereby authorize LifeWise Assurance Company (LifeWise) to initiate debit and/or credit entries to our bank account indicated below. We acknowledge that the origination of Automated Clearing House (ACH) transactions to our account must comply with applicable law.

|Bank Name |      |

(e.g., Bank of America, Washington Mutual)

|Bank Routing Number |      |

(e.g., nine-digit ABA number)

|Bank Account Number |      |

Type of Account (please check one) Checking Savings

|Bank Account Name |      |

(e.g., general checking account, operating account)

In addition, and as a courtesy, please send an e-mail notification to inform us of the amount of funds being debited or credited to our bank account. (E-mail notifications are sent approximately 48 hours prior to ACH settlement.) This e-mail should be directed as follows:

|Name |      | |E-mail |      |

| | | |

|Title |      | |Phone |(     )     -      |

This authorization is to remain in full force and in effect until LifeWise has received written notification from us of its termination in such time and in such manner as to afford LifeWise and our bank a reasonable opportunity to act on it. We understand that changes to any information on this form must

be directed to our LifeWise billing representative by the close of business Tuesday to ensure that these changes will take effect by the following week.

A revised form will only be required in the event that there are changes to any banking information.

The undersigned is authorized to sign this funding authorization on behalf of the company.

|Signature | | Date |      |

|Title |      | | |

For LifeWise Assurance Company Use Only:

Group Policy Number _____________________________ Divisions ___________________

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