make life easier with UniPAY - Utica National

1 UniPAY . Payment Option make life easier with UniPAY . 9-A-1599 Ed. 2-13. Authorization for Utica National 's UniPAY . UniPAY is the convenient and safe way to Utica National independent insurance agent, Electronic Funds Transfer Program pay your insurance premiums! Our UniPAY or if you have a current UNIBILL account, I(we) authorize the Utica National Insurance Group, option enables you to have your insurance mail the agreement back to us with your or its subsidiary or affiliated companies, to debit/credit premiums paid automatically, in up to 12* next insurance payment. the financial institution account(s) as listed below for payment of the policy premium as premium(s) become equal monthly installments, from your bank due. I(we)further authorize said financial institution to In order to update your banking records or credit union account.

2 Honor such debit/credit entries to my(our) account(s). accordingly, you will be notified prior to the I(we) agree that if a debit/credit is dishonored, the With UniPAY , no large, lump-sum payment initial withdrawal, of the monthly withdrawal financial institution shall have no liability even if the is required. And, you can avoid the problems amount. Should this amount change for any dishonored debit/credit results in the forfeiture of insur- ance. I(we) agree that only written notification from me associated with mailing payments, including: reason, you will be notified approximately (the insured) to the financial institution and to the Utica Mail delays 15 days prior to any change that results in National Insurance Group, or its subsidiary or affiliated companies, will cause this agreement to be termi- Rising postal rates modification of your premium amount.

3 Nated. Should a debit request be dishonored by the Late payments Should you have questions, please contact Financial Institution, Utica National Insurance Group may change the amount of future debits to reflect the Late fees the independent agent near you who repre- payment of the policy premium over a 10-month period Service charges sents the companies of the Utica National from commencement of the policy term. I understand that Utica National Insurance Group may also debit my To initiate the service, simply fill out the Insurance Group or call us at 1-800-59 Utica account for any premiums in arrears. attached authorization agreement and (1-800-598-8422). UNIBILL Account Number or Policy Number(s): submit a voided check (if your deductions *Depending on the term of the policy.)

4 Are to be taken from that account) to your _____. _____. Insured Name:_____. (Please Print) Phone #:_____. Financial Institution Name: _____. Bank Routing # _____. Checking Acct. # _____. Savings Acct. # _____. Share Acct. # _____. Day of Month for Withdrawal: _____. Check Number Account Number Signature _____. (Insured) (Date). Bank Routing Number RETURN THIS WITH YOUR CURRENT PAYMENT DUE. appears between these symbols