Jack Bontrager

I am a very dependable worker always on time and willing to learn new things

• BID AFT AUTH 03 21, AUTOMATED FUNDS TRANSFER (AFT) AUTHORIZATION
• DO NOT include the bank account number or any other sensitive banking information, All sections must be completed in order to process this request.
• By signing this form, I hereby authorize Midvale Indemnity Company to initiate deductions from my account described above, in the form of an electronic funds transfer or preauthorized check only for payment of amount due the Company. This authority shall remain in effect until I give written or verbal notice to my agent or by calling at least ten (10) days before the effective date of termination. I understand that Midvale Indemnity Company reserves the right to terminate the processing of my payments through this AFT arrangement at any time.
• I understand I may not receive notification in these instances:, My draw amount is less than my statement amount due to payment by other means, policy cancel or premium credit.
• PREAUTHORIZED PAYMENT PLAN AGREEMENT FOR Midvale Indemnity Company., 1. I authorize Midvale Indemnity Company to deduct premiums from the above account for the below listed insurance policies which I purchase later and specify AFT as the form of payment. Such deductions are subject to the terms listed above. 2. If an authorized deduction is not honored by my financial institution, I understand Midvale Indemnity Company may terminate this preauthorized payment plan agreement and that my policies may lapse. 3. If the plan is terminated by either me or Midvale Indemnity Company, I will be responsible to pay premiums directly to Midvale Indemnity Company and any of its subsidiary companies. 4. I understand that this preauthorized payment plan does not modify or affect any policy provisions.
• SIGNATURE REQUIRED (Signature of depositor as it appears on record at financial institution), X
• DATE
• Account/Policy # Name of Insured, CP00035218 Jack Bontrager
• Electronically Signed 2024-05-08 19:09:19 UTC - 166.194.136.42, Nintex AssureSign 7d33c4b3-ac9c-4a68-be2e-b16a01395a08
• 2024-05-08 15:09:26 (UTC-04:00), Digitally signed by Nintex eSignReason: Electronic Signatureprocess for envelope'87f1de10-10b5-468e-9b8c-b16a013959f1' completedsuccessfully via NintexAssureSignLocation: prd-us-primaryDigitally