Electronic Funds Transfer (EFT) Request Form (Withdrawal)
Choose payment date between 1st and 28th:_____
Phone
I hereby request and authorize you to draw on my account maintained at the above named Financial Institution, the payment to NGL for subsequent payment on the policy(ies). It is agreed that:
1. NGL may process an immediate one-time withdrawal to pay any past-due premium on my policy(ies).
2. Proof of payment will appear on your bank statement.
3. This authority will remain in effect until I have cancelled it in writing. I can discontinue this method of payment with five day written advance notice.
4. In the event that the payment is not honored, NGL has the right to re-present the transaction. NGL also has the right to revoke this method of payment at any time.
5. This method of payment will not change any of the provisions of my policy(ies) and the amount drawn will be the amount reflected in the policy contract and/or policy endorsement. In the event of an error in the withdrawal, NGL has the right to perform the corrective deposit to rectify the error within 5 banking days of the transaction.
6. If the person indicated on this form is not listed as the payor on the policy they may be changed to the payor.
7. Paying premiums other than on an Annual basis may be more costly. Unless indicated on this form the draw will occur monthly.
8. The draw will be started on the date indicated above, but the actual date of withdrawal can vary due to holidays/ weekends and is dependent on your Financial Institution.
of Depositor
For your protection, California law requires the following to appear on this form: Any person who knowingly presents false or fraudulent information to obtain or amend insurance coverage or to make a claim for the payment of a loss is guilty of a crime and may be subject to fines and confinement in state prison.