The person identified below has authorized U.S. Insurance Company of America (USICOA) to debit the bank account electronically through the Automated Clearing House (ACH). USICOA will initiate the debit to the bank account and it will post to the account the next business day.
This form authorizes USICOA, its successors and/or assignees to automatically draft from the checking or savings account one-time for the scheduled amount. The identified personnel authorizes the bank to make payments from the account directly to USICOA. Furthermore, the individual agrees that such withdrawal and payment should be treated as if they personally signed for the withdrawal and payment. If such withdrawal/payment is dishonored, intentionally or inadvertently, USICOA shall be under no liability with respect thereto and the insured will be charged a $50 rejected payment fee.