COUNTRY LIFE INSURANCE COMPANY®
PAYMENT AUTHORIZATION ("Payment Authorization")

Automatic Payment Information

Payor (“I” or “me” or “you”) hereby authorizes COUNTRY Life Insurance Company® (“CLIC”) and/or COUNTRY Investors Life Assurance Company® (“CILAC”) to arrange with my bank to debit (withdraw) from my checking or savings account the appropriate dollar amount(s) at the frequency(ies) indicated on or around the date(s) indicated to pay the premium amount(s) associated with the policy(ies)/contract(s) purchased from CLIC, CILAC, and/or Cotton States Life Insurance Company®, and any related fees. The above activity will hereinafter be referred to as a “transaction.”

I also acknowledge that the withdrawal amount(s) for the CLIC, CILAC and/or CSLIC policy(ies)/contract(s) will be based on amount indicated. I must verify my bank statements for accuracy. I authorize CLIC/CILAC to keep this payment information on file for future use. If I change my checking or savings account, financial institution, name, or address, I must make the change via my COUNTRY Financial online account (https://www.countryfinancial.com) or notify CLIC/CILAC of the change by (1) contacting an agent or (2) calling the client service center at 1-866-COUNTRY (268-6879). To the extent I am entitled to receive payment-related notices, I agree to waive my right to receive these notices and authorize CLIC/CILAC to send such notices to the policy owner on my behalf, if I am not the policy owner. I agree CLIC/CILAC will provide the policy owner, if different than the bank account owner, on the bank account owner’s behalf, with a premium notice that will detail the automatic payment setup if the policy owner has elected to receive such notices. With the potential exception of the initial draw, any premium notices will be sent at least ten (10) calendar days prior to the next subsequent draw.

I authorize CLIC/CILAC to refund to me any payment in excess of the agreed upon amount, and, if necessary, apply the refund to the referenced bank account and/or electronically debit or credit my bank account to correct any transaction(s). To the extent that any funds are due to the policy owner, I authorize CLIC/CILAC to electronically credit the referenced bank account.

I acknowledge that it is my responsibility to have sufficient funds available in this bank account to cover these withdrawals. To the extent I am entitled to receive payment-related notices, I agree to waive my right to receive these notices and authorize CLIC/CILAC to send such notices to the policy owner on my behalf, if I am not the policy owner. In the event that a payment is rejected, the policy owner, if different than the bank account owner, will be sent a separate correspondence from CLIC/CILAC requesting a replacement payment covering the withdrawal as well as any returned item fees. If payment is not received within the required timeframe, I understand the policy(ies)/contract(s) may lapse.

I attest I am authorized to initiate this ACH transaction(s).

Terms and Conditions

Please confirm the details of this transaction(s). By electronically signing where indicated, you accept this Payment Authorization and these Terms and Conditions, and your acceptance constitutes binding authorization to CLIC/CILAC to initiate regularly scheduled ACH/electronic debit entries to your financial institution account. You understand and agree that the amount(s) and date(s) of the withdrawal(s) is determined by the payment plan you select. If you do not wish to authorize this transaction(s), please exit the payment process.

This Payment Authorization will remain in full force and effect regardless of any cancellation, nonrenewal, or other termination of any of the CLIC, CILAC and/or CSLIC policy(ies)/contract(s). You further agree that CLIC/CILAC has the right, absent termination of this Payment Authorization, to collect by automatic withdrawal any agreed upon amount(s) even if any of the policies/contracts are cancelled, nonrenewed, or otherwise terminated.

This Payment Authorization will remain in full force and effect until it is terminated by you or CLIC/CILAC upon written notice. For any termination to be effective, the terminating party must provide three (3) business days’ prior notice. By terminating this Payment Authorization, you understand that you will be canceling all future automatic payments associated with this Payment Authorization and that this will not apply to any previously processed payments. Both the policy owner and the bank account owner, if different than the policy owner, may terminate this Payment Authorization. You may terminate this Payment Authorization via your COUNTRY Financial online account (https://www.countryfinancial.com) or request CLIC/CILAC terminate by (1) contacting an agent, or (2) calling the client service center at 1-866-COUNTRY (268-6879).

You understand the ACH/electronic debit entries will be withdrawn from your bank account on the scheduled payment date(s) for the agreed upon amount(s). The withdrawals will begin with the first scheduled payment date. You understand that a payment(s) with a scheduled date(s) on a Saturday, Sunday, or holiday may not be processed until the following business day.

If you have elected to receive information via email regarding automatic payments, you agree to maintain a current/up-to-date email address with CLIC/CILAC, and you will ensure that it is active and capable of receiving new emails. You will ensure that your email account has sufficient space for new emails and your email server and spam-blocking software do not block CLIC/CILAC emails. You understand that CLIC/CILAC is not responsible for problems arising from emails sent to an inactive/out-of-date email address, unless CLIC/CILAC is solely negligent for using an incorrect address.

You authorize CLIC/CILAC to use a third party to process the authorized automatic payment(s) on its behalf.

It is recommended that this Payment Authorization be downloaded, saved, and/or printed and maintained for your records.

Privacy Policy: To view our privacy policy, go to https://www.countryfinancial.com/en/privacy-and-security/privacy-and-security-policy.html.

System Requirements/Equipment: CLIC/CILAC uses encryption to make your information unreadable as it passes over the Internet. Therefore, CLIC/CILAC strongly recommends that you use the latest version of your browser software for maximum security. Should CLIC/CILAC make any changes to hardware or software requirements for electronic presentation such that you will no longer be capable of accessing or retaining your billing statements and notices electronically, CLIC/CILAC will inform you of the revised hardware and software requirements.

CLIC/CILAC reserves the right to change this Payment Authorization, which includes these Terms and Conditions, at any time, and, if changes are made, CLIC/CILAC will inform you.