IMPORTANT INSTRUCTIONS FOR
COMPLETING AN AGREEMENT FOR RECURRING ELECTRONIC
FUND TRANSFERS FORM
This form is to be used for the following companies and will be referred to as "The Company" in this document.
a
Everlake Assurance
Everlake Company Company
Life Insurance
PLEASE READ CAREFULLY!
Upon completion of this form and submission to The Company, this form is considered final upon receipt. Updates cannot
be made to a final form. Note: When completing the form, if updates necessary and are made prior to submission, any/all
changes must be initiated and dated by the Bank Account Holder(s).
Please read this form in its entirety to ensure you are aware and understand the agreement/authorization. All three
pages of the form are required to be completed and submitted to The Company. The Company may deem a new form
is required for reasons other than what is disclosed within the instructions and/or terms of the agreement.
This form is policy specific; please ensure that you capture the full and correct policy number(s) which you are authorizing
drafts.
This agreement is for up to four in-force policies. When multiple policies are provided, section B must clearly identify the
appropriate drafting instructions for each policy; if preferred, you may complete multiple page 2's for each policy (clearly
identify which page relates to which policy).
Section A (Account Information)
Complete all applicable fields; print clearly to prevent delays and/or the need for additional paperwork.
Please print Bank Account Holder and/or Joint Bank Account Holder Name. Note: Signatures are required on page 3.
Joint Bank Account Holder Name - Optional, however, if the intent is for all bank account holders to have
authorization to make changes, then all Bank Account Holder names and signatures are required.
Bank Account Holder Address - Optional, however useful if the Payor differs from the Owner. If not provided, any
refunds will be mailed to the Owner.
A voided check is not required to accompany the form; however, it is helpful and may be required if the information
provided in Section A is not legible. Note: If Section A is completed and a voided check is provided, they must be
consistent.
Section B (Recurring Payment)
In order to authorize recurring payments, at least one field/box must be indicated. Completion of frequency and/or draft
date does not constitute completion of this section. The draft date will be the same date the policy is issued. If an
alternate draft date is desired, it may cause multiple drafts from customer account depending on date selected. If the
alternate draft date is after the monthiversary, it will require two modal premium drafts when initiated. For this section to
be considered complete, you must also complete the policy number, recurring payment amount, and payment frequency
fields. If this section is left blank, a new form may be required.
Section C (Agent Authorization)
If you indicate “I/We DO NOT GIVE” authorization, the bank account holder/owner will be responsible for making any
necessary changes to recurring premium amount, mode frequency, draft date and/or loan initiation or repayment. This is
for the life of your application and/or policy or until you change this option, which can be completed at any time and as many
times as you deem necessary.
Section D (Disclosures and Signatures)
Please read carefully! If the bank account holder differs from the policy owner, as least one bank account holder is
required to sign and date the form.
Date is a required field and must be legible to The Company or a new form will be required.
If the Owner(s) is different from the Bank Account Holder(s) they are required to sign the form acknowledging
disclosures and who the Bank Account Holder/Payor(s) is.
This form is policy specific and cannot be transferred or used for a companion file without express consent in writing by
the Bank Account Holder(s) and Owner(s).
At any time, The Company may determine that a new EFT form is necessary if the form is not completed appropriately,
contains incorrect information or if there are changes to information provided in the form. If a new form is required, you
will be notified.
FIC413EFTIF (01/23)
AGREEMENT FOR RECURRING ELECTRONIC FUND TRANSFER
bEverlake
Everlake Assurance
Assurance Company
Company
PO
P.O.BOX
Box83328,
83328, LINCOLN,
Lincoln, NENE 685013328
68501 FAX: (833) 6360034
FAX: 1-833-636-0034
Everlake Life Insurance Company
Everlake Life Insurance Company
P.O.BOX
PO Box83328,
83328, LINCOLN,
Lincoln, NENE
68501 FAX: 1-833-636-0034
685013328 FAX: (833) 6360034
I (We) authorize Everlake Assurance Company or Everlake Life Insurance Company (“The Company”) and its other affiliates
to debit my (our) account indicated to pay the premiums/payments, and other charges (such as non-sufficient funds), from
the account listed on this form.
A. ACCOUNT INFORMATION - This agreement is for In-Force Contract(s)/Policy(ies) (Please list all policy/contract
numbers to be billed from this account in Section B.)Your bank, savings and loan, or credit union must be a member of the
Automated Clearing House (ACH) network and your account type must permit electronic transfers. You may provide
or be asked to provide a voided check. If so, please attach it over the voided check below.
Routing Number Account Number
Financial Institution ("The Institution")
Account Type Checking Savings
Bank Account Holder Name Joint Bank Account Holder Name (If Applicable)
Owner (if Other than Bank Account Holder) Joint Owner (If Applicable)
Bank Account Holder Address (Street Address, City, State, Zip) Bank Account Holder's Phone
Number
Owner’s Address (If other than Bank Account Holder's Address) (Street Address, City, State, Zip)* Owner's Phone Number
* If the owner's address listed above does not match the current address in our system, we will update our
records. If you do not want us to change your address, please leave the Owner's address field blank.
(Attach a VOID check here)
Bank Account Registration
VOID
ABA Routing # Bank Account #
Home Office Copy (01/23)
FIC413EFTIF
Page 1 of 3
B. RECURRING PAYMENT INFORMATION - Use this section to select your payment amount, draft date and
frequency for your scheduled withdrawals.
I (We) authorize The Company and its affiliates, and the financial institution designated to deduct payments from my (our)
account through electronic funds transfer. I (We) further authorize The Company to make changes to my (our) draft date;
premium amount; mode frequency and/or initiate or change a loan repayment amount upon my (our) written, verbal or
electronic request(s). All such requests will be confirmed by The Company in writing.
NOTES: If a frequency is not selected, withdrawals will be monthly. The draft date will be the same date the policy is issued,
unless a draft date is selected below. If the draft date does not occur in a given month, the draft will occur on the last day
of the month. Not all Payment Frequencies may be available for all products.
Policy Number 1:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
Policy Number 2:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
Policy Number 3:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
Policy Number 4:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
C. AGENT AUTHORIZATION - If a box isn't checked, your agent will be able to make changes on your behalf.
I (We) give my acting agent the authorization to make the following EFT changes: draft date; premium amount; mode
frequency and initiate or change loan repayment. Any such request will be confirmed by The Company in writing.
I/We GIVE my agent authorization to make the above changes on my behalf.
I/We DO NOT GIVE my agent authorization to make the above changes on my behalf.
Please sign on page 3
Home Office Copy (01/23)
FIC413EFTIF
Page 2 of 3
D. DISCLOSURES AND SIGNATURES
This authorization shall not be construed as: (a) an approval by The Company of the application; or (b) a modification of
any provisions of any existing coverage.
Electronic debit entries shall be initiated by The Company to pay premiums and other charges and fees for or associated
with the policy listed on this document or other policies as authorized and the entries shall constitute my receipt for the
transaction(s).
This Agreement is to remain in effect until The Company terminates it or until I (we) contact my agency or notify The
Company in writing or by phone of termination and allow 5 business days for The Company to act on it. I (we) understand
I (we) have the right to contact my financial institution to place a one-time stop payment. This agreement may be ended
automatically by The Company if any debit entry has been refused by The Institution because of insufficient funds in my
(our) account.
I (We) understand that I (we) will be asked to complete a new Electronic Funds Transfer form if the account information
provided is incorrect, if my (our) bank account information changes or if this agreement is terminated by either The Company
or the customer and I (we) wish to be reset back onto Electronic Fund Transfer.
If the Agreement ends for any reason, and premium/payment is not paid beyond its grace periods, all premiums/payments
due on any policy/contract covered by this agreement will become directly payable to The Company by me (us) until
payment/ premium plan is agreed to in writing.
I (We) will retain a copy of this form for my (our) records.
The signature below is exactly as it appears in The Institution's records for this account.
In addition, I (we) have read, fully understand and also agree to the provisions on this form.
If the bank account holder and the owner are not the same, both the bank account holder and the owner must
sign.
Sign Here
Signature of Owner, Date Signature of Joint Owner, if other than Bank Date
if other than Bank Account Holder Account Holder
Signature of Bank Date Signature of Joint Bank Account Date
Account Holder Holder, if any
Home Office Copy (01/23)
FIC413EFTIF
Page 3 of 3
AGREEMENT FOR RECURRING ELECTRONIC FUND TRANSFER
bEverlake Assurance Company
Everlake Assurance Company
PO
P.O.BOX
Box 83328, LINCOLN,
83328, Lincoln, NENE 685013328
68501 FAX: (833) 6360034
FAX: 1-833-636-0034
Everlake Life Insurance Company
Everlake Life Insurance Company
P.O. Box 83328,
PO BOX 83328, Lincoln, NENE
LINCOLN, 68501 FAX: 1-833-636-0034
685013328 FAX: (833) 6360034
I (We) authorize Everlake Assurance Company or Everlake Life Insurance Company (“The Company”) and its other affiliates
to debit my (our) account indicated to pay the premiums/payments, and other charges (such as non-sufficient funds), from
the account listed on this form.
A. ACCOUNT INFORMATION - This agreement is for In-Force Contract(s)/Policy(ies) (Please list all policy/contract
numbers to be billed from this account in Section B.)Your bank, savings and loan, or credit union must be a member of the
Automated Clearing House (ACH) network and your account type must permit electronic transfers. You may provide
or be asked to provide a voided check. If so, please attach it over the voided check below.
Routing Number Account Number
Financial Institution ("The Institution")
Account Type Checking Saving
Bank Account Holder Name Joint Bank Account Holder Name (If Applicable)
Owner (if Other than Bank Account Holder) Joint Owner (If Applicable)
Bank Account Holder Address (Street Address, City, State, Zip) Bank Account Holder's Phone
Number
Owner’s Address (If other than Bank Account Holder's Address) (Street Address, City, State, Zip)* Owner's Phone Number
* If the owner's address listed above does not match the current address in our system, we will update our
records. If you do not want us to change your address, please leave the Owner's address field blank.
(Attach a VOID check here)
Bank Account Registration
VOID
ABA Routing # Bank Account #
Customer Copy
FIC413EFTIF Page 1 of 3 (01/23)
B. RECURRING PAYMENT INFORMATION - Use this section to select your payment amount, draft date and frequency
for your scheduled withdrawals.
I (We) authorize The Company and its affiliates and the financial institution designated to deduct payments from my (our)
account through electronic funds transfer. I (We) further authorize The Company to make changes to my (our) draft date;
premium amount; mode frequency and/or initiate or change a loan repayment amount upon my (our) written, verbal or
electronic request(s). All such requests will be confirmed by The Company in writing.
NOTES: If a frequency is not selected, withdrawals will be monthly. The draft date will be the same date the policy is issued,
unless a draft date is selected below. If the draft date does not occur in a given month, the draft will occur on the last day
of the month. Not all Payment Frequencies may be available for all products.
Policy Number 1:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
Policy Number 2:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
Policy Number 3:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
Policy Number 4:
Recurring Payment Amount Payment Frequency:
Monthly Quarterly Semiannual Annual
Draft Date
C. AGENT AUTHORIZATION - If a box isn't checked, your agent will be able to make changes on your behalf.
I (We) give my acting agent the authorization to make the following EFT changes: draft date; premium amount; mode
frequency and initiate or change loan repayment. Any such request will be confirmed by The Company in writing.
I/We GIVE my agent authorization to make the above changes on my behalf.
I/We DO NOT GIVE my agent authorization to make the above changes on my behalf.
Customer Copy
FIC413EFTIF Page 2 of 3 (01/23)
D. DISCLOSURES AND SIGNATURES
This authorization shall not be construed as: (a) an approval by The Company of the application; or (b) a modification of
any provisions of any existing coverage.
Electronic debit entries shall be initiated by The Company to pay premiums and other charges and fees for or associated
with the policy listed on this document or other policies as authorized and the entries shall constitute my receipt for the
transaction(s).
This Agreement is to remain in effect until The Company terminates it or until I (we) contact my agency or notify The
Company in writing or by phone of termination and allow 5 business days for The Company to act on it. I (we) understand
I (we) have the right to contact my financial institution to place a one-time stop payment. This agreement may be ended
automatically by The Company if any debit entry has been refused by The Institution because of insufficient funds in my
(our) account.
I (We) understand that I (we) will be asked to complete a new Electronic Funds Transfer form if the account information
provided is incorrect, if my (our) bank account information changes or if this agreement is terminated by either The Company
or the customer and I (we) wish to be reset back onto Electronic Fund Transfer.
If the Agreement ends for any reason, and premium/payment is not paid beyond its grace periods, all premiums/payments
due on any policy/contract covered by this agreement will become directly payable to The Company by me (us) until
payment/ premium plan is agreed to in writing.
I (We) will retain a copy of this form for my (our) records.
The signature below is exactly as it appears in The Institution's records for this account.
In addition, I (we) have read, fully understand and also agree to the provisions on this form.
If the bank account holder and the owner are not the same, both the bank account holder and the owner must
sign.
SIGNATURES NOT REQUIRED ON CUSTOMER COPY
Sign Here
Signature of Owner, if other than Bank Account Holder Date Signature of Joint Owner, if other than Bank Account Holder Date
SIGNATURES NOT REQUIRED ON CUSTOMER COPY
Signature of Owner, if other than Bank Account Holder Date Signature of Joint Owner, if other than Bank Account Holder Date
Customer Copy
FIC413EFTIF Page 3 of 3 (01/23)
