Payment Authorization Form - easyway insurance brokers

Coachman Insurance Company
Payment Authorization Form
Bank Account Holder
Broker Name
Street and Number
Street and Number
Postal Code
Insured (if different than bank account holder)
Broker #
Policy Number
Product Type
Effective Date
New Request
Down payment
Monthly withdrawal
Pref withdrawal date (1 - 28TH)
Change of Existing Information
Finance Fees: 3% of total premium
Please attach void cheque or bank account verification form and fully complete this form.
- I/We have been provided with details of and understand the terms and conditions of the payment plan by automatic withdrawals from my/our financial institution account.
- I/We hereby authorize the named financial institution below to debit my/our account for all payments payable to Coachman Insurance Company in payment of the
insurance premiums and any applicable charges and taxes.
- I/We understand that this authorization may be cancelled by me/us upon written notice, subject to a period which shall not exceed 30 days. The payor(s) may obtain a
sample cancellation form, or further information on their right to cancel a payment authorization agreement, at their financial institution or by visiting
- I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any debit that is not
authorized or is not consistent with this payment authorization agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial
institution or visit
- I/We warrant and guarantee that all persons whose signatures are required to sign on this account have signed this authorization below.
- If there is a change in premiums due to a change in coverage or upon renewal, the amount of the monthly withdrawal will automatically be changed.
- I/We will ensure that funds are available on each due date and understand that Non-Sufficient Funds transactions may result in one or all of the following:
1. A second presentation or attempt to withdraw funds. 2. Cancellation of my/our payment plan agreement. 3. Cancellation of my/our policy.
- I/We have received a copy of this authorization and have read and understand these terms and conditions.
- I/We acknowledge that this authorization concerns only pre-authorized debits in the following categories in accordance with Rule H1 of the Canadian Payments
Association: pre-authorized debits.
- For pre-authorized debits, I/we shall receive, with respect to the debiting of fixed-amount payments, written notice from Coachman Insurance Company, the amount to
be debited and due date(s) debiting, at least 10 calender days prior to the date of the first payment and such notice shall be received each time there is a change in the
amount of payment.
- The account that my/our financial institution is authorized to draw upon is indicated below. A specimen cheque has been marked "void" and attached to this authorization.
- I/We undertake to inform Coachman Insurance Company, in writing, of any change in the account information provided in this authorization prior to the next payment
due date.
- I/We acknowledge that Coachman Insurance Company is not required to verify that the pre-authorized debit was issued in accordance with the particulars of the Payor's
Authorization including, but not limited to, the amount.
- I/We understand that this authorization is continuous and will automatically apply to the renewal terms, unless instructed differently.
- I/We authorize Coachman Insurance Company to collect or use my/our personal information for the purpose of this authorization for automatic withdrawals for
payments of my/our insurance premiums. I/We authorize Coachman Insurance Company to disclose any personal information contained in this authorization form to
its financial institution to the extent disclosure is directly related to and necessary for the proper execution of the pre-authorized debit transaction for the policy number(s)
noted above.
- I/We may obtain a copy of or ask questions about my/our broker's and Coachman Insurance Company's personal information policies by contacting their respective
privacy officers.
- I/We may withdraw my/our consent to collect, use or disclose my/our personal information for the purpose of this authorization for automatic withdrawals for payment of
my/our insurance premiums. Withdrawal of my/our consent will result in cancellation of this authorization for automatic payment of my/our insurance premiums, in which case
I/we must make other arrangements for payment of my/our insurance premiums.
Monthly Pay Plan Authorization
Signature(s): x
1) Payor/Valid Signing Authority
2) Payor/Valid Signing Authority
Pre-authorized withdrawals are not available for Three Pay.
1st installment (40%)
Due with application
2nd installment (30% + $10 fee)
Due in 2 months (Invoiced)
3rd installment (30% + $10 fee)
Due in 4 months (Invoiced)
CREDIT CARD AUTHORIZATION for Three Pay 1st installment (40%) or Monthly Pay down payment.
American Express
Card Number
Expiry Date
Cardholder Name:
Amount $
Signature x
Please note that a $50 Payment Return Fee may apply to any returned payment.
Fax: Toronto 416-255-3347 or Regina 1-866-888-5488, or send by courier/Canada Post in a Company Bill envelope
WEB 8023-6
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