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HCC Surety Group 601 South Figueroa Street Suite 1600 Los Angeles California 90017 AUTHORIZATION TO CHARGE CREDIT/DEBIT CARD The undersigned authorizes AMERICAN CONTRACTORS INDEMNITY COMPANY UNITED STATES SURETY COMPANY or U.S. SPECIALTY INSURANCE COMPANY hereafter called HCC SURETY to charge the credit/debit card listed below. This authority is to remain in full force and effect until HCC SURETY has received written notification from me of its termination 10 days prior to the next scheduled charge date. HCC SURETY reserves all of its rights and defenses pursuant to the applicable bond s agreement s including indemnity agreement s the law or otherwise. CREDIT/DEBIT CARD INFORMATION CARD TYPE VISA MASTERCARD DISCOVER AMERICAN EXPRESS CARD NUMBER CARD EXPIRATION DATE CARD SECURITY CODE see below CARDHOLDER INFORMATION CARDHOLDER NAME CREDIT CARD BILLING ADDRESS Office Use Only To be completed by HCC Surety PAYMENT DETAIL PAYMENT TYPE PREMIUM SUBROGATION OTHER BOND/CLAIM/COLLATERAL NUMBER AGENCY ID PRINCIPAL S NAME if different than cardholder NAME OF HCC SURETY ASSOCIATE MONITORING REIMBURSEMENT S ONE TIME PAYMENT AMOUNT RECURRING PAYMENTS INITIAL DOWN PAYMENT DOWN PAYMENT AMOUNT RECURRING PAYMENT FINAL PAYMENT st th DAY OF THE MONTH TOTAL NUMBER OF RECURRING PAYMENTS TO BE AUTO BILLED including the final payment NUMBER OF PAYMENTS LAST SCHEDULED RECURRING PAYMENT DATE Card security code is the three digit code on the back of Visa or MasterCard or the four digit code on the front of American Express. The last scheduled recurring payment may be recalculated in the event that any of the recurring payments are not made as scheduled* I hereby declare that I am the holder of the above credit/debit card. I authorize the above mentioned amounts to be charged to the credit/debit card per the terms indicated herein* Cardholder s signature Date For cardholder security please submit the signed form via fax to 310 649-1061 or e-mail to CCPayments hccsurety. This authority is to remain in full force and effect until HCC SURETY has received written notification from me of its termination 10 days prior to the next scheduled charge date. HCC SURETY reserves all of its rights and defenses pursuant to the applicable bond s agreement s including indemnity agreement s the law or otherwise. HCC SURETY reserves all of its rights and defenses pursuant to the applicable bond s agreement s including indemnity agreement s the law or otherwise. CREDIT/DEBIT CARD INFORMATION CARD TYPE VISA MASTERCARD DISCOVER AMERICAN EXPRESS CARD NUMBER CARD EXPIRATION DATE CARD SECURITY CODE see below CARDHOLDER INFORMATION CARDHOLDER NAME CREDIT CARD BILLING ADDRESS Office Use Only To be completed by HCC Surety PAYMENT DETAIL PAYMENT TYPE PREMIUM SUBROGATION OTHER BOND/CLAIM/COLLATERAL NUMBER AGENCY ID PRINCIPAL S NAME if different than cardholder NAME OF HCC SURETY ASSOCIATE MONITORING REIMBURSEMENT S ONE TIME PAYMENT AMOUNT RECURRING PAYMENTS INITIAL DOWN PAYMENT DOWN PAYMENT AMOUNT RECURRING PAYMENT FINAL PAYMENT st th DAY OF THE MONTH TOTAL NUMBER OF RECURRING PAYMENTS TO BE AUTO BILLED including the final payment NUMBER OF PAYMENTS LAST SCHEDULED RECURRING PAYMENT DATE Card security code is the three digit code on the back of Visa or MasterCard or the four digit code on the front of American Express.

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