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Get Texas Life Insurance Company Bank Draft Authorization Form

AUTOMATIC BANK DRAFT AUTHORIZATION P. O. Box 341899 Austin Texas 78734 - PH 800 756-7306 - FAX 512 263-6981 Financial Institution Name Address City State Zip Telephone Account Holder Name Type of Account Checking Savings Routing No. Account No. Please Pay And Charge My Account All Drafts Drawn By TEXAS SERVICE LIFE INSURANCE COMPANY. To Its Own Order Once Each check one In The Amount of Monthly Quarterly Semi-Annually Annually BEGINNING DATE MM/DD/YY This authorization will remain in effect until cancelled by me in writing and until you actually receive such notice. I understand that any drafts processed within a period of fourteen 14 days of receipt of a written request to cancel this authorization may be presented to my bank account. I agree that you shall be fully protected in honoring any such draft for a period of fourteen 14 days after you receive such notice. I agree that your treatment of each such draft and your rights in respect to it shall be the same as if it were signed personally by me. I further agree that if no BEGINNING DATE is cited above then the Company may draft my account on either 1 THIRTY 30 DAYS from the date of the Policy/Contract 2 the first installment date shown on the Insurance Application or 3 a date communicated in writing by the Company to the undersigned account holder. Policy/Contract No* s Signature of Account Holder/PAYOR Print Name Date PLEASE ATTACH A VOIDED CHECK Deposit slip or ticket is not acceptable Telephone 512 263-6977 Toll Free 800 756-7306 Fax 512 263-6981 WS. To Its Own Order Once Each check one In The Amount of Monthly Quarterly Semi-Annually Annually BEGINNING DATE MM/DD/YY This authorization will remain in effect until cancelled by me in writing and until you actually receive such notice. I understand that any drafts processed within a period of fourteen 14 days of receipt of a written request to cancel this authorization may be presented to my bank account. I understand that any drafts processed within a period of fourteen 14 days of receipt of a written request to cancel this authorization may be presented to my bank account. I agree that you shall be fully protected in honoring any such draft for a period of fourteen 14 days after you receive such notice. I agree that you shall be fully protected in honoring any such draft for a period of fourteen 14 days after you receive such notice. I agree that your treatment of each such draft and your rights in respect to it shall be the same as if it were signed personally by me. I agree that your treatment of each such draft and your rights in respect to it shall be the same as if it were signed personally by me. I further agree that if no BEGINNING DATE is cited above then the Company may draft my account on either 1 THIRTY 30 DAYS from the date of the Policy/Contract 2 the first installment date shown on the Insurance Application or 3 a date communicated in writing by the Company to the undersigned account holder. I further agree that if no BEGINNING DATE is cited above then the Company may draft my account on either 1 THIRTY 30 DAYS from the date of the Policy/Contract 2 the first installment date shown on the Insurance Application or 3 a date communicated in writing by the Company to the undersigned account holder. Policy/Contract No* s Signature of Account Holder/PAYOR Print Name Date PLEASE ATTACH A VOIDED CHECK Deposit slip or ticket is not acceptable Telephone 512 263-6977 Toll Free 800 756-7306 Fax 512 263-6981 WS.

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