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Recurring Electronic Payment Authorization

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					 Recurring Electronic Payment Authorization
I authorize Hastings Mutual Insurance Company to transact recurring electronic funds transfer transactions to the
account designated below. I hereby request my Financial Institution to accept and honor debit and/or credit entries
from my account. I request that this authorization continue to apply for any subsequent payments or changes in
products or services until revoked by me in writing, allowing fifteen days upon receipt of the notice for Hastings
Mutual Insurance Company to act upon the request. Transactions will be processed at the time payment is due to
Hastings Mutual Insurance Company. This preauthorized payment agreement will remain in effect until revoked by
either party.

Although notice of withdrawal will be sent to me before subsequent payments are withdrawn from my account,
there may be infrequent exceptions where no notice is given. Withdrawals may vary due to adjustments to down
payment, installment plan, changes in coverage, and fees. Cancellation of a policy does not cancel the recurring
payment authorization. I recognize that Hastings Mutual Insurance Company may, at its sole discretion, terminate
the plan immediately if any transactions are not honored when presented for payment.

This authorization in no way modifies any terms of the insurance policy or policies, nor does the authorization,
absent payment, constitute acceptance of any offer which may be made by Hastings Mutual Insurance Company
to renew an insurance policy.

I agree that the Financial Institution’s right’s with respect to each transaction shall be the same as if it were a
check drawn on my account and signed personally by me. I further agree that if any such transaction is dishon-
ored, whether with or without cause and whether intentionally or inadvertently, the Financial Institution shall be
under no liability whatsoever if such dishonor results in cancellation of my insurance and/or loss of benefits.

If the Recurring Electronic Funds Transfer Payment option is requested for a new account, the down payment
must accompany the application.

Direct invoices should be paid until a notice of EFT withdrawal is received.


RECURRING ELECTRONIC PAYMENT APPLICATION:
What day of the month are the funds to be paid ____________________

NAME (MUST BE AN AUTHORIZED SIGNER ON THE BANK ACCOUNT LISTED BELOW.)                    TELEPHONE NUMBER (AREA CODE AND PHONE #)


BILLING ACCOUNT NUMBER (FROM YOUR INVOICE)                    (If this is a new account, please leave blank.)


BANK NAME (OR ATTACH A VOIDED CHECK)
                                  K


BANK ROUTING NUMBER (OR ATTACH A VOIDED CHECK)                (9 digits located on the bottom left of the check.)


BANK ACCOUNT NUMBER (OR ATTACH A VOIDED CHECK)                                            CHECK ONE
                                                                                          F    Checking     F Savings


BILLING PLANS:          F   MONTHLY     F    BIMONTHLY    F    QUARTERLY             F    SEMIANNUAL                F   ANNUAL   (SELECTION REQUIRED)

Please allow 30 days for the withdrawal to be effective.
Date: _______________________________            Signature: _________________________________

                    Please read important information regarding the authorization on the reverse side.

Form No. 2-976 (11/05)                                                                                                                                  Page 1 of 2

				
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