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									    The Penn Mutual Life Insurance Company                                               Request to Make Premium Payments
    The Penn Insurance and Annuity Company                                                        Under the Penn Check Plan
    Philadelphia, PA 19172
    Customer Service 1-800-523-0650                                                                                    Life Insurance
                   Please complete Sections B and C. Then mail page one of this form along with a voided check from the bank
                   account, or Pershing Resource Checking or Pro Cash Plus account, on which the draft is to be drawn. If
                   your savings account does not have check writing, send a bank statement or other form that has your account number,
       A.          the bank’s routing and transit codes to:
 INSTRUCTIONS
                                               The Penn Mutual Life Insurance Company
                                               The Penn Insurance and Annuity Company
                                               Customer Service Group - C3U
                                               Philadelphia, PA 19172

                      New Plan                  Banking Change            Draw Date:        1st      8th       15th      22nd

                   Penn Mutual or Penn Insurance and Annuity will draw a check against your account each month on the date you
                   have selected above. Enter the policy number(s) to be placed on the Penn Check Plan and the amount to be
                   deducted for each policy.

                   Policy #: ______________ Amount: _____________               Policy #: ______________ Amount: _____________
      B.
    POLICY         Policy #: ______________ Amount: _____________               Policy #: ______________ Amount: _____________
 INFORMATION
                   Policy #: ______________ Amount: _____________               Policy #: ______________ Amount: _____________

                   The Penn Mutual Life Insurance Company/ Penn Insurance and Annuity Company is hereby requested and authorized
                   to charge the bank account, or Pershing Resources Checking or Pro Cash Plus account, listed under Section C by
                   means of check, draft or other order drawn, or an electronic fund transfer initiated, at monthly intervals, to pay premiums
                   under each policy listed above. Permission to do so is subject to the provisions on page two of this request form.


                   I authorize monthly payments from my checking account, or from my Pershing Resource Checking or Pro Cash Plus
                   account, to the Penn Mutual Life Insurance Company and/or the Penn Insurance and Annuity Company for premiums
                   on the above policies, beginning with the next periodic payment that comes due under the contract, until such time as a
                   payment cannot be made due to insufficient funds or Penn Mutual Life Insurance or Penn Insurance and Annuity
                   Company give the other parties at least 30 days’ advance written notice of the termination of such payment plan. I am
                   able to cancel the payment plan at any time by either calling Penn Mutual Life Insurance Company and/or the Penn
                   Insurance and Annuity Company at 1-800-523-0650 or in writing. Monthly payments will be drawn from my account on
                   or about the date specified above.
      C.
                   I further agree that if any such check be dishonored, whether with or without cause and whether intentionally or
     BANK
                   inadvertently, the Penn Mutual and/or Penn Insurance and Annuity Company shall be under no liability whatsoever
 INFORMATION       even though such dishonor results in the forfeiture of insurance.
     AND
AUTHORIZATION
                   Bank Name:                              ______________________________________________________________
                   (If Pershing account, enter "Pershing")

                   Address (Bank only):                     ______________________________________________________________

                   City, State and Zip:                     ______________________________________________________________

                   Bank or Pershing Account Number:         _______________________________________           Checking              Savings
                                                            (Voided check must be attached to complete transaction.)

                   First Depositor’s Name:                  ______________________________________________________________

                   Second Depositor’s Name:                 ______________________________________________________________
                   (Use for Joint Accounts)
                   Depositor’s Signature:                   _________________________________________ Date: ________________

                   Depositor’s Signature:                   _________________________________________Date:_________________
                                                            (If payor is a company or corporation, two officers must sign and indicate titles.)
      D.
  HOME OFFICE      PCP Account Number: ________________________
     USE

7444A 2/04                                                                                                                      Page 1 of 2
                                The Penn Mutual Life Insurance Company
                                The Penn Insurance and Annuity Company
                                            Penn Check Plan



GENERAL INFORMATION

1.   Penn Mutual or Penn Insurance and Annuity will draw a check against your checking, savings or Pershing
     Resource Checking or Pro Cash Plus account each month, on the date you have selected, to pay premiums on
     your policy(ies).

2.   Annual increases are automatically made if your policy’s provisions include automatic premium increases. If
     you have universal life policies, you have the option to increase your contributions. We will send a checkbook
     reminder indicating any change to your deduction amount so that you can adjust your checkbook.

3.   To notify us of a bank change, call our toll-free number. We will send you a new authorization form to complete
     and return to us.

4.   This plan can be cancelled at any time. Just call our toll-free number, 1-800-523-0650, and we will cancel the
     plan.


PROVISIONS

1.   The premium-payment method for premiums payable by check, draft or other order drawn, or electronic fund
     transfer under the Penn Check Plan (“Plan”) will be monthly. If dividends are being used to reduce premiums
     and no other option is elected, all future dividends will be used to purchase paid-up additional insurance unless
     the paid-up additional insurance option is not available under the policy. In this case, dividends will accumulate
     at interest.

2.   The Plan is to apply to the payment of premiums due after the date of this request, subject to the following
     provisions:

     a)   In the case of a new policy, the Plan will not be effective until payment of the initial premium. If the initial
          premium has been applied to coverage under a Temporary Insurance Agreement, and an additional
          premium is required to bring payment current to the date the plan will be effective, that additional premium
          must also be paid.

     b)   In the case of an existing policy, the Plan will not be effective until payment of all premiums due on or
          before the date this request is delivered to the Company issuing the policy has been made.

3.   If premiums are now payable other than monthly and the due date of any unpaid premium is past or will fall due
     before the Plan becomes effective, the method of premium payment will be changed to monthly, commencing
     on the due date of such premium.

4.   The privilege of paying premiums under the Plan will terminate (a) upon dishonor of any check, draft or other
     order drawn, or an electronic fund transfer initiated under the Plan, or (b) upon notification by the depositor,
     policy owner, or the Company issuing the policy. A check, draft or other order drawn, or an electronic fund
     transfer will be considered dishonored if not paid upon presentation or if paid in error by the drawee bank.

5.   Upon and after termination of the Plan, the amount of premium for the affected policy will be at the rate
     that applied to the policy when it was not under the Plan. The premium payment schedule will change to
     quarterly. This change to quarterly premium payments will be effective beginning in the second policy
     quarter that occurs after the due date of the last premium paid under the Plan.




7444A 2/04                                                                                                 Page 2 of 2

								
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