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:


Example: Jr, Sr, III.


-

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


Please provide the following:


Example: jdoe@domainname.com (no spaces)
( ) - -

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

Add




Banking Information

( ) - -


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

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.