RECURRING ACH DEBIT AUTHORIZATION AGREEMENT

By clicking on the “Accept” button below, I hereby authorize TruAssure Insurance Company to deduct the premium amount stated above from the listed bank account on or about the 27th of each month for my monthly premium payment (if the payment method selected is monthly). I understand that the initial ACH debit to my account will occur immediately and if I have selected an annual payment option, the initial ACH debit will reflect the annual premium.

I agree that this authorization will remain in full force and effect until TruAssure has received written notification from me that I am terminating it, and I must give TruAssure at least 3 days prior written notice to terminate this authorization or to change the designated bank account.

I understand that TruAssure will notify me in advance of any changes to the charged amount. By completing this form, I hereby authorize TruAssure and the bank identified above to process the ACH debits authorized here.

If I am not the insured person under this policy, I confirm that I am agreeing to pay this insurance premium on behalf of the insured person. Unless the insured person is a minor for whom I am a parent or legal guardian, I understand that any changes to the policy that may affect the charge amount will be communicated to the insured person only.

I agree that if I have any problems or questions regarding this authorization or my insurance policy, I will contact TruAssure for assistance at 888-559-0781. I guarantee that I am the account holder for this bank account and that I am legally authorized to enter into this recurring ACH Debit Authorization Agreement with TruAssure.

If my financial institution rejects an ACH debit from TruAssure due to insufficient funds, I understand and agree that TruAssure may in its discretion attempt to process the charge again within 30 days. I understand that if my bank dishonors any ACH debit requested by TruAssure under this agreement, TruAssure may assess me a $25 service charge, and TruAssure may collect that service charge by means of an ACH debit. I also understand that TruAssure may apply that service charge each time it resubmits an ACH debit request that is rejected (even if it is for the same unpaid amount as a previously-rejected ACH debit request).

FOR INDIVIDUALS IN ALL STATES BUT KANSAS: I understand that if my bank dishonors any ACH debit requested by TruAssure under this agreement, TruAssure may assess me a $25 service charge, and TruAssure may collect that service charge by means of an ACH debit.

FOR INDIVIDUALS IN KANSAS: I understand that if my bank dishonors any ACH debit requested by TruAssure under this agreement, subsequent payment of any premium due will not keep the Policy in force, except as provided in the Grace Period. If any premium due is not received by TruAssure before or at the end of the Grace Period, the Policy will automatically terminate at the end of the period for which the last premium was paid.
 

BE SURE TO PRINT AND KEEP A COPY OF THIS FORM FOR YOUR RECORDS.