Electronic Funds Transfer Authorization - …

1 Online EFT Payment Authorization v. 03-11-2014 1 Electronic Funds Transfer Authorization Terms & Conditions SECTION I ONE TIME EFT WITHDRAWAL On behalf of _____ (insert full name of insured) referred to as the Insured , I authorize _____ (insert agency name) and its affiliates and subsidiaries ( Agency ) to initiate a one-time Electronic Funds Transfer ( EFT ) withdrawal by Continental Casualty Company and its affiliates and subsidiaries ( CNA ) using Automated Clearing House ( ACH ) processing. EFT withdrawal via ACH is the Transfer of Funds from a business account for the purposes of making a payment. For policy number: _____ Insured name: _____ Bank Name Bank Routing Number (9 digits) Bank Account Number For the payment of premium to CNA in the following amount: $_____ I certify that I have provided the Insured s banking account routing number and account number to the Agency.

2 I have also attached a copy of a voided check or deposit slip with this Authorization . Account Type: Commercial Checking I certify that I am an authorized signer for the Insured and for this account. I also authorize the financial institution where this account is held to honor the withdrawal. I acknowledge it is the Insured s responsibility to have sufficient Funds in this account to cover each withdrawal authorized. If, for any reason, CNA does not receive the premiums due for the policy reference above, I understand that the policy may cancel or expire. I understand that the Insured must execute this form each time the Insured asks the Agency to make a one-time EFT payment on its behalf. _____ _____ Name (please print) Company e-mail address (to send Electronic payment confirmation) _____ Title _____ Signature Date AGENTS: If processing a one-time EFT payment for your customer, retain this completed and signed Authorization (Section I) in your files for at least two years.

3 Complete Section II if setting up automatic EFT payments Online EFT Payment Authorization v. 03-11-2014 2 SECTION II automatic EFT WITHDRAWALS On behalf of _____ (insert full name of insured) referred to as the Insured , I authorize _____ (insert agency name) and its affiliates and subsidiaries ( Agency ) to initiate a one-time Electronic Funds Transfer ( EFT ) withdrawal by Continental Casualty Company and its affiliates and subsidiaries ( CNA ) and set-up automatic EFT payments on my behalf using Automated Clearing House ( ACH ) processing. EFT withdrawal via ACH is the Transfer of Funds from a business account for the purposes of making a payment. For policy number: _____ Insured name: _____ Bank Name Bank Routing Number (9 digits) Bank Account Number For the payment of premium to CNA in the following amount: $_____ I certify that I have provided the Insured s banking account routing number and account number to the Agency.

4 I have also attached a copy of a voided check or deposit slip with this Authorization . I agree that the ACH Payment I authorize comply with all applicable law. Account Type: Commercial Checking I acknowledge that automatic EFT withdrawals will be deducted from the account identified above on the date the premium is due for the total amount due pursuant to my installment payment plan. I understand that payments with due dates falling on a Saturday, Sunday, or holiday may be processed the following business day. I understand and agree that the amounts and dates of the withdrawals are determined by the payment plan selected for the policy and are not flexible. I also understand that CNA will provide prior notice of EFT each EFT withdrawals and notify me if the amount of the EFT withdrawal changes.

5 I certify that I am an authorized signer for the Insured and for this account. I authorize the financial institution where this account is held to honor the withdrawals. I understand that this Authorization will remain in full force and effect until I (or the Agency on my behalf) notify CNA in writing via that I wish to revoke this Authorization . I acknowledge that I must provide written Authorization to the Agency if the Agency is to revoke this Authorization on my behalf. I understand that CNA requires at least two weeks prior notice in order to cancel the Authorization I acknowledge it is the Insured s responsibility to have sufficient Funds in this account to cover each withdrawal authorized. If, for any reason, CNA does not receive the premiums due for the policy reference above, I understand that the policy may cancel or expire.

6 I understand that any automatic withdrawal that is refused due to insufficient Funds may be resubmitted at the CNA s discretion. If I choose to discontinue automatic EFT withdrawals or change my account information, I can do so by going to by withdrawing online or by providing written notice to the Agency using the information below or by contacting CNA Customer Service at PHONE # 877-276-7507 or send an email to Attention: Agency Information You will receive written confirmation of your enrollment and any changes you request. To change my account information, I will complete and submit a new Authorization form. The written notice to discontinue EFT withdrawals or change account information must be given in enough advance notice that it provides two weeks to act on the request before the next withdrawal is made.

7 If I decide to discontinue EFT withdrawals I will check the status of my policy. If I decide to cancel my policy, I will check the status of my outstanding bills at that time. _____ _____ Name (please print) Company e-mail address (to send Electronic payment confirmation) _____ Title _____ Signature Date AGENTS: If processing a recurring EFT payment for your customer, retain this completed and signed Authorization (Section II) in your files for at least two years after the automatic EFT withdrawals cease.