AUTHORIZATION AGREEMENT FOR AUTOMATIC …

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Infinity Select Insurance Company5205 N. O Connor Blvd., Suite 700Irving, TX 75039 AUTHORIZATION AGREEMENT FOR AUTOMATIC withdrawal OF MONTHLY PAYMENTS ___ New Policy (Keep in Agency File) ___ Change to Bank Information (Fax to 1-877-841-5224) *** The customer MUST receive a copy of this AUTHORIZATION *** I hereby authorize Infinity Insurance Companies and its subsidiaries, hereinafter called Infinity, to initiate monthly deductions from my bank account identified below. These monthly withdrawals will be payment of premium and fees on the insurance policy issued by Infinity to me, and any renewals thereafter.

Infinity Select Insurance Company 5205 N. O’Connor Blvd., Suite 700 Irving, TX 75039 AUTHORIZATION AGREEMENT FOR AUTOMATIC WITHDRAWAL OF MONTHLY PAYMENTS

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