The initial premium will be drafted upon the effective date of coverage. The applicant may select any day for the renewal premiums to be drafted excluding the 29 th , 30 th or 31 st of the month. Note: if the initial EFT is returned non-sufficient funds (NSF) payment will be called due, the policy will transition to quarterly direct bill mode, and the initial premium will be required to activate the coverage. If the initial premium is drafted successfully and any renewal premiums are returned NSF, payment automatically will be called due and the policy will transition to quarterly direct bill mode. DIRECT BILL Acceptable forms of payment: • Personal checks • Electronic bill pay (from applicant) • Business check (business owner must be applicant or spouse of applicant) The following forms of payment are NOT acceptable: • Temporary checks • Money orders • Cashier checks MONTHLY BANK DRAFT AND DIRECT BILL FOR EMPLOYEES • The Company accepts business on monthly bank draft, list bill and direct bill methods of payment The annual, semiannual and quarterly modes of payment are acceptable for all forms of payment • In completing a bank draft form, please print all information starting with the name of the bank to be drafted as well as their city and state • A voided sample check along with a completed bank draft authorization form signed by the payor is required. PROCESSING DELAYS If an application is submitted with incomplete, unclear, or missing information critical to the risk evaluation, a new application may be required or an amendment to the application will be issued Critical information includes, but is not limited to: • Plan • Complete residential address • Date of birth • Any health question left blank • Applicant’s signature • Agent’s signature • The application is received at the administrative office more than 60 days from the signature date • Authorization and Certification section was not completed and signed • Replacement forms not submitted when applicable • Agent appointment was not granted by the company when the application was solicited • If the amount quoted on the application is less than the modal premium we calculate, we will contact the agent to verify that it is acceptable to process the bank draft for the amount that we have calculated We will amend the modal premium • The Company will not accept deposit slips in the place of voided checks AMENDMENTS/ENDORSEMENTS An Amendment and/or Endorsement to the application will be generated for the following reasons: • Any question left blank or answered incorrectly • An error or unclear answer for the plan selection and/or underwriting risk classification • An error or unclear answer for the date of birth, sex, and/or address • An error or unclear answer for the modal premium GUARANTEED RENEWABLE FOR LIFE Your policy cannot be cancelled regardless of changes in health, the number of times benefits are received or advancing age The only way the policy can be cancelled is for failure to pay premiums The Company reserves the right to change the rates on all policies of this class in the entire state
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FOR AGENT USE ONLY
AGT-CP4000 0216
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