BANK DRAFT AUTHORIZATION - American Amicable
American - Amicable Life Insurance Company of Texas IAAmerican Life Insurance Company Industrial Alliance Insurance and Financial Services, Inc. Occidental Life Insurance Company of North Carolina Pioneer American Insurance Company Pioneer Security Life Insurance Company DRAFT Box 2549, Waco, TX 76702-2549Toll-Free 800-736-7311 Fax 254-297-2105(Please use black ink)PLEASE NOTE: You may make this change on our websites or by completing and returning this form. List ALL policy numbers to be drafted: ________________________________________ ________________________________________ ________________________________________ _______________________________ Payor Name (Please Print): ________________________________________ _____________________________Bank Name / Address:________________________________ ________________________________________ _9 digit ABA / Routing #: _________________
BANK DRAFT AUTHORIZATION P.O. Box 2549, Waco, TX 76702-2549 Toll-Free 800-736-7311 • Fax 254-297-2105 (Please use black ink) PLEASE NOTE: You may make this change on our websites or by completing and returning this form. List ALL policy numbers to be drafted: _____
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