For Customer Support, Call 1-800-523-9100

To add coverage, call 1-877-877-8052

New York Residents call 1-800-323-4542
Call Center Hours

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Request Automatic Bank Account Deduction

To have premiums automatically deducted from a bank account, complete and submit the form below. If you are not the person we insure, include your information in the section provided.

Questions? Please call 1-800-523-9100. NY Residents call 1-800-323-4542.

Your request will be processed within the next few business days.

Note: For Medicare Supplement plans issued in 2010 or later, please call 1-800-800-2254 for customer service for your policy.

(*) Means required field

Please complete the following information about the person we insure:

Title:

Mrs

Miss

First Name of Insured: *

Middle Initial:

Last Name of Insured: *

Suffix:

Example: Jr, Sr, III.

Street address: *

City: *

State: *

Zip/Postal Code: *

If you are not the insured, please complete the following:

First Name:

Middle Initial:

Last Name:

Relationship to the Insured:

Please provide the following:

Your E-mail: *

Example: [email protected] (no spaces)

Your Daytime Telephone: *

( ) - -

Enter Policy Number(s)
To pay for more than one policy click the Add link.

Policy Number:

Remove

Add

Billing Frequency: *

Monthly	Quarterly
Annual	Semi‑Annual

Banking Information

Bank Name: *

Bank Telephone No:

( ) - -

Bank Account Number: *

Verify Bank Account Number: *

Type of Account: *

Checking

Savings

Money Market

Select the Month and Day
for Deductions to Begin: *

(choose from the 3rd to the 28th day of the month)

Bank Routing Number
(9 digits): *

check

I certify that I am the account holder for the bank account named above. By clicking on 'I Agree', I authorize Colonial Penn Life Insurance Company to initiate electronic debit or credit entries for insurance premium payments for the
account(s) listed above from the bank account listed above. I authorize the bank named above to deduct the insurance premium from this account. I understand each premium for this insurance will be paid through my account directly to Colonial Penn as the premium comes due. I further understand that the first automatic withdrawal from my account may be for two premiums (if paying monthly) and will be deducted regularly thereafter. Double deductions may also occur if the insurance is in arrears. First drafts returned for insufficient funds will be resubmitted a second time. This authorization is to remain in effect until I write a letter authorizing Colonial Penn and my bank to cancel the automatic premium payment plan. I also agree to give Colonial Penn and my bank a reasonable opportunity to act on my request.

Your name, as it appears on your bank account: *

I Agree

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Colonial Penn Life Insurance Company
Bankers Conseco Life Insurance Company

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Home of the Colonial Penn® Program

The Colonial Penn® Program is underwritten in most states by and is a registered trademark licensed by Colonial Penn Life Insurance Co, Philadelphia, PA. For policies issued in NY, the Colonial Penn® Program is underwritten by and is a registered trademark licensed by Bankers Conseco Life Insurance Co, Jericho, NY. Colonial Penn Life Insurance Co is not licensed in and does not solicit business in the state of New York. Policies underwritten by Intramerica Life Insurance Co are administered by Bankers Conseco Life Insurance Co.