Gerber Life Insurance Company Mail signed and…

        Gerber Life Insurance Company
        Mail signed and completed form to:
        Gerber Life Insurance Company, 445 State Street, Fremont, MI 49412 or in Canada, 2233 Argentia Road,
        Suite 200, Mississauga, ON L5N 9Z9.
With the Automatic Payment Plan, there's no need to write monthly checks or remember due dates. We'll automatically
send a transaction to your financial institution on or near the due date. The money is deducted from your account, with
your bank statement serving as a record of premiums paid. Enrollment is easy! Just follow these steps:

1. Complete, print and sign this authorization form.
2. For bank approval, write "VOID" across a blank, unsigned check.
3. Attach the voided check to your form, and mail it to the address listed above.

Cancel this privilege at any time by notifying Gerber Life. Please allow 7 days for processing.

                                  AUTOMATIC PAYMENT PLAN AUTHORIZATION FORM

I hereby authorize the bank or financial institution named on the attached sample below to pay my insurance
premium every month (or at the time period checked below) by check or electronic account debits drawn by
and payable to Gerber Life Insurance Company.
The bank or financial institution will be fully protected in honoring these payments until written notice
cancelling this request is received.
Policyowner Name _____________________________________________________________________________
                               First Name                      Middle Initial                        Last Name
Address _________________________________________________________ Phone (_____) _______________
City _________________________________ State/Province _________ Zip Code/Postal Code ____________
Gerber Life Policy Number(s) ____________________________________________________________________
Name of person(s) insured under this policy _______________________________________________________
Accountholder's name (please print) ______________________________________________________________
X __________________________________________________________________                       Date____/____/____
                  (Accountholder's Signature)

Preferred billing method (check one):       Monthly     Bi-monthly       Quarterly   Semi-Annually        Annually




                                                      Attach Check Here
  Write "VOID" across the face of your blank check as shown. Be sure it is not signed. Your Automatic Payment
  Plan will be processed as soon as possible. Please be sure your checking account is adequately funded.



                       John Doe                                                       1000
                       000 Main Street
                       Any Town, USA 12345                                           _________19___

                       PAY TO THE

                                                          O ID
                       ORDER OF___________________________________________ $


                       MEMO________________
                                                      V
                       ___________________________________________________________DOLLARS
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