Payer's Client Number

Direct Debit Authorization Form

Please print name(s) as it appears in the Bank records

or

ACCOUNT TYPE:

(Please tick one)

Chequing
Savings

Bank Routing#

FOR INTERNAL USE ONLY

Do you have any existing Premium Payment facilities in favour of Guardian Life that you wish to cancel?

(If Yes, please complete a STOP PAYMENT AUTHORIZATION FORM )

DETAILS OF POLICY (IES)
Policy
Number(s)
Name(s) of
Person(s) Insured
PREMIUM
Amount
LOAN
Amount
TOTAL
Amount
TOTAL

(Day/Month/Year)
The neccessary number of person(s) authorized on the nominated bank account above must sign this form. For Incorporated or Partnership accounts the Company's Stamp is also required.

Thank You for choosing Direct Debit...

The safest, quickest and cheapest way to pay your premiums!

DRAW FREQUENCY:

(Please tick one)

MONTHLY
QUARTERLY
SEMI-ANNUAL
ANNUAL

Place Company
stamp here

DD v.13MAR2017
See overleaf for Q&A