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Get Canada BMO Insurance Request for Pre-Authorized Payment

CY NUMBER: I/We authorize BMO Life Assurance Company to debit the account below to pay premiums, including overdue premiums, for the above numbered policy(ies) and any other policy(ies) I/We designate, on the _________ day of each month or the next business day. Attach a sample Cheque marked “VOID” NAME OF PAYOR: (please print) NAME OF FINANCIAL INSTITUTION: ADDRESS OF FINANCIAL INSTITUTION: BRANCH NUMBER: ACCOUNT NUMBER: Declaration: I/We have chosen to make payments of premium using t.

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