Capitol Insurance Company



Capitol Insurance Company

Fax to: 215-956-9436 or - 800-394-3291

AUTHORIZATION AGREEMENT FOR ELECTRONIC FUNDS TRANSFER

I (we) hereby authorize Capitol Insurance Company, its subsidiaries and affiliates, to initiate electronic debit and credit entries to my (our) checking account identified below. This authority pertains to payment of premium on the insurance policy and any renewals thereof, issued to me (us) by Capitol Insurance Company.

I (we) authorize the financial institution named below to honor the debit and credit entries initiated by Capitol Insurance Company and post such entries to my (our) account. I (we) represent that I (we) am (are) the owner(s) and/or an authorized signer(s) on the account.

I (we) understand that this authorization allows Capitol Insurance Company to adjust the debit and credit entries to reflect any premium changes, including policy renewals. I (we) understand that this authorization allows Capitol Insurance Company to deduct from my (our) checking account amounts due to Capitol Insurance Company, including earned premiums should my (our) insurance coverage be canceled for any reason. Capitol Insurance Company agrees to notify me (us) of any change in the debit amount prior to the posting of entries to my (our) account. Installment fee per invoice is $6.00.

I (we) understand that both the financial institution and Capitol Insurance Company reserve the right to terminate this payment plan and/or my participation therein at any time. I, too, can elect to discontinue my participation in this plan by providing written notice to Capitol Insurance Company within a sufficient amount of time (1 week) to afford Capitol Insurance Company and the financial institution to act on it prior to the next payment date. Being removed from the EFT payment plan can change my(our) due date, installment amount due, number of invoices or all three depending on where I(we) currently am (are) in the installment billing process.

I (we) understand that participation in this payment plan shall in no way alter or amend the provisions of the policy issued by Capitol Insurance Company.

Insured Name: _______________________________________________ Policy:_____________

Name(s) on account:________________________________________________

________________________________________________

Routing/ABA # ___________________________________________________

Checking Account # ________________________________________________

IMPORTANT NOTICE FOR CREDIT UNION MEMBERS: Many smaller credit unions use a different account number than the one shown on your check. You may wish to verify your account number through your local office to assure proper setup for withdrawals.

Signature: ____________________________________________ Date:_______________

(Must be a person authorized to sign on this account)

Signature: ____________________________________________ Date:_______________

(Must be a person authorized to sign on this account)

PLEASE PROVIDE A VOIDED CHECK FOR CONFIRMATION PURPOSES

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