Get Aflac A91195 2006-2024

Payment Authorization Agreement Policyholder/Applicant Information Policy Numbers Name Address City State ZIP Phone Premium No. of policies Total Deduction Information When would you like your premiums deducted Please choose any day 1 28. How often Monthly Quarterly Semiannually Annually For newly issued policies only For ease of your policy administration we will make the effective date of coverage the same as your selected draft date following the receipt of your application in worldwide headquarters. I choose to pay by electronic draft. Draftee Name Depository Name/Branch City Transit/ABA Number Account Number State ZIP Checking Savings Visa MasterCard American Express Card Number Credit card Debit card Expiration Date Confirmation I authorize Aflac to initiate debit entries electronically to my account indicated above and I authorize the depository institution named above to debit same to such account. Payment Authorization Agreement Policyholder/Applicant Information Policy Numbers Name Address City State ZIP Phone Premium No* of policies Total Deduction Information When would you like your premiums deducted Please choose any day 1 28. How often Monthly Quarterly Semiannually Annually For newly issued policies only For ease of your policy administration we will make the effective date of coverage the same as your selected draft date following the receipt of your application in worldwide headquarters. I choose to pay by electronic draft. Draftee Name Depository Name/Branch City Transit/ABA Number Account Number State ZIP Checking Savings Visa MasterCard American Express Card Number Credit card Debit card Expiration Date Confirmation I authorize Aflac to initiate debit entries electronically to my account indicated above and I authorize the depository institution named above to debit same to such account. This authorization remains effective and in full force until Aflac and the depository/institution have received written notification from me of its termination in such time and in such manner to afford Aflac and the depository/institution a reasonable opportunity to act on it. Associate s/Agent s Signature Writing Number Date Required for SNG Only A91195 American Family Life Assurance Company of Columbus Aflac Worldwide Headquarters 1932 Wynnton Road Columbus GA 31999-0001 1. Payment Authorization Agreement Policyholder/Applicant Information Policy Numbers Name Address City State ZIP Phone Premium No* of policies Total Deduction Information When would you like your premiums deducted Please choose any day 1 28. How often Monthly Quarterly Semiannually Annually For newly issued policies only For ease of your policy administration we will make the effective date of coverage the same as your selected draft date following the receipt of your application in worldwide headquarters. How often Monthly Quarterly Semiannually Annually For newly issued policies only For ease of your policy administration we will make the effective date of coverage the same as your selected draft date following the receipt of your application in worldwide headquarters. I choose to pay by electronic draft. Draftee Name Depository Name/Branch City Transit/ABA Number Account Number State ZIP Checking Savings Visa MasterCard American Express Card Number Credit card Debit card Expiration Date Confirmation I authorize Aflac to initiate debit entries electronically to my account indicated above and I authorize the depository institution named above to debit same to such account.