American Independent Companies Inc - AIICO

1 American Independent Companies Inc. ELECTRONIC FUNDS TRANSFER (EFT) AUTHORIZATION I authorize American I ndependent Companies I nc., and its corporate and company affiliates (" company ") to initiate scheduled deductions from the bank account, i dentified below, for payment of premium on the i nsurance policy i ssued to me by the company , and any renewals thereof, and to initiate credit entries to the account to correct any erroneous deductions. I (we) authorize the financial institution identified by the routing number below to accept and post entries to the account. I represent that I am the owner and/or an authorized signer of the account. I understand and acknowledge the following: - The company will not send me a bill before regularly scheduled deductions are made and it is my responsibility to ensure sufficient funds are in the account at the time of each scheduled deduction.

2 - An EFT installment fee will be charged and deducted with each monthly installment payment. This fee as with all fees is subject to change and will be reflected on the payment schedule or 10 day written notification of change that is sent to me. - This authorization allows the company to adjust the scheduled deductions to reflect any premium changes and the company agrees to notify me with a revised i nvoice at least ten (10) days prior to making any deduction that will be more than the previous deduction. If the actual deduction taken is l ess than the scheduled amount, confirmation will also be reflected in the form of a revised i nvoice. - My policy may cancel or expire if there are i nsuffici ent funds in the account and I will be responsible for any NSF fee, late fee, or cancellation fee that may be applied.

3 If a balance is due after the expiration or cancellation date, I may be billed or notified of a future electronic deduction. - If appropriate replacement funds are made for i nsufficient funds resulting in a reinstatement, the automatic deductions will resume (not applicable if account i s closed, frozen, unauthorized or i nvalid). - This authorization does not change or alter any provisions of the i nsurance policy. - The origination of the ACH (Automated Clearing House) transactions to the account must comply with the provisions of l aw. - This authorization will remain in effect until I notify the company of i ts termination in writing in such time and manner as to afford the company a reasonable opportunity to act on it.

4 Policy Number: _____ Named Insured: _____ Address and Phone Number if different than that shown on your policy: _____ Checking Account [ ] Saving Account [ ] Name on Account: _____ Routing Account: _____ Account Number: _____ Signature (Must be a person authorized to sign on this account) X_____ Date: _____ Signature of Insured X_____ Date: _____ Signature of Agent ATTACH VOIDED CHECK HERE Please retain this form in your office for new business. If making account changes for a policy or adding to a renewal policy, please fax this to form to our secure fax line: 770-303-2527 or secure email.