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

Payment information

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

I authorize CLIC to refund to me any payment in excess of the premium amount due, and, if necessary, apply the refund to the referenced debit/credit card and/or charge my debit/credit card to correct any transaction(s). To the extent that any funds are due to the policyholder, I authorize CLIC to electronically credit the referenced debit/credit card.

I acknowledge that it is my responsibility to have sufficient funds available on this debit/credit card to cover this charge. To the extent I am entitled to receive payment-related notices, I agree to waive my right to receive these notices and authorize CLIC to send such notices to the policyholder on my behalf, if I am not the policyholder. In the event that a payment is returned for insufficient funds, the policyholder, if different than the debit/credit card owner, will be sent a separate correspondence from CLIC requesting a replacement payment covering the charge 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 debit/credit card transaction(s).

Terms and Conditions

Please confirm the details of this transaction(s). By electronically signing below (via signature pad, clicking a box, etc.), you accept this Payment Authorization and these Terms and Conditions, and your acceptance constitutes binding authorization to CLIC to initiate a one-time charge to your debit/credit card. A receipt of payment, including this Payment Authorization, will be mailed and/or emailed to you. If you do not wish to authorize this transaction(s), please exit the payment process.

This Payment Authorization is only valid for this transaction (one-time use). If this transaction is scheduled for a future date, this Payment Authorization will remain in full force and effect until it is either (1) terminated by you upon written notice; (2) terminated by CLIC upon written notice; or (3) the transaction has been processed. For any termination to be effective, the terminating party must provide three (3) business days’ prior notice. For any transaction scheduled for a future date, the termination of this Payment Authorization will result in the canceling this scheduled payment. Both the policyholder and the debit/credit card owner, if different than the policyholder, may terminate this Payment Authorization. You may terminate this Payment Authorization via your COUNTRY Financial online account (https://www.countryfinancial.com) or request CLIC terminate by (1) contacting a financial representative/specialist or insurance agent, or (2) calling the client service center at 1-866-COUNTRY (268-6879).

You understand the debit/credit card charge will be processed on the scheduled payment date(s) for the amount(s) due. 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 payments, you agree to maintain a current/up-to-date email address with CLIC, 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 emails. You understand that CLIC is not responsible for problems arising from emails sent to an inactive/out-of-date email address, unless CLIC is solely negligent for using an incorrect address.

You authorize CLIC to use a third party to process the authorized 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 uses encryption to make your information unreadable as it passes over the Internet. Therefore, CLIC strongly recommends that you use the latest version of your browser software for maximum security. Should CLIC 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 will inform you of the revised hardware and software requirements.

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