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Electronic Payment (EP) Account Agreement: Things To Know Before You Begin

This document is an electronic payment account agreement used to establish or change electronic payments for insurance policies. It collects information needed to set up automatic withdrawals from a bank account, including the type of request, bank account and owner details, policy information, bank routing number, and signatures. By signing, the bank account owner agrees to the terms and authorizes the insurance company to make withdrawals as specified.

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andry
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165 views4 pages

Electronic Payment (EP) Account Agreement: Things To Know Before You Begin

This document is an electronic payment account agreement used to establish or change electronic payments for insurance policies. It collects information needed to set up automatic withdrawals from a bank account, including the type of request, bank account and owner details, policy information, bank routing number, and signatures. By signing, the bank account owner agrees to the terms and authorizes the insurance company to make withdrawals as specified.

Uploaded by

andry
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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Electronic Payment (EP) account agreement

Use this form to establish or change an electronic payment.

Company (Check the appropriate ONE.)


The Company indicated in this section is referred to as "the Company".
Metropolitan Life Insurance Company Metropolitan Tower Life Insurance Company

Things to know before you begin


• Instructions: Use this form to establish or change an electronic
payment account as a payment method for policies and contracts
issued by the companies listed above. Once you have established an
EP account, other products can be included with this account so that
payments can be withdrawn on the same date from the same bank
account.
• If you need assistance completing this form, please call your Please complete this form
representative, sales office, or the appropriate number listed under How in its entirety to avoid any
to submit this form. delays in processing.

SECTION 1: Type of request


New authorization (To make regular withdrawals)
Change of bank account (Prior authorization)
Add policy/contract to existing Electronic Payment account #

SECTION 2: Bank account Owner information


Primary Owner of the bank account: Individual or Business entity
First name Middle name Last name

Business entity

Street address City State ZIP

Joint Owner of the bank account:


First name Middle name Last name

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DEBITAUTH-05 (05/20) Fs/f
SECTION 3: Policy/Contract payment information
Please complete the following Policy/Contract Policy/Contract Policy/Contract Policy/Contract
chart using a separate number number number number
column for each policy/
contract.
Recurring payment type:
Please choose one or more
of the following: Premium,
Loan repayment, Annuity,
PUAR, etc.
Recurring payment
amount:
Amount to draft every month
Relationship of bank
account Owner to Contract
Owner:
Please choose one of the
following: Self, Spouse/
Domestic Partner, Parent,
Trustee, Business Owner,
Step Parent, Child,
Grandparent,
Employer, or Guardian.
* Please review Bank Draft
Disclosure for additional
information.
Initial premium advance
payment amount:
*Please review Bank Draft
Disclosure for additional
information.
Withdrawal Date is the day of the month we will withdraw from your bank account. If you do not specify a
date, monthly withdrawals will occur on the same day of the month as the issue date.
Please specify only one option: Issue date of Policy/Contract Withdrawal on the of each month

SECTION 4: Bank information


Account Type: Checking Savings

We CANNOT establish electronic payments from some


brokerage, mutual funds or from foreign bank accounts
(unless it is being paid in U.S. Dollars through a U. S.
correspondent bank.)

Banking institution routing number

Account number

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DEBITAUTH-05 (05/20) Fs/f
Name of bank Bank address & branch where account is located

If this is a brokerage account, please provide Firm name

SECTION 5: ACH withdrawal authorization


I, the Bank Account Holder, hereby authorize
1. The Companies named above (MetLife) to initiate withdrawal entries to the deposit account designated
above at the Bank named above, using the Automated Clearing House;
2. Monthly recurring withdrawals in the amount set forth in Section 3 above and such additional amounts that
may be required under the terms and conditions of the relevant policy/contract; and
3. Withdrawals made from time to time, as I authorize.
I understand that:
1. The origination of electronic withdrawals to my account must comply with the provisions of U.S. law;
2. MetLife requires notification of a least two business days before a scheduled payment to either terminate
the EP account or to prevent a scheduled payment.
3. If payments are made for insurance premiums, paying my insurance premiums monthly may result in a
higher yearly out-of-pocket cost or different cash values.
4. Premiums may increase in accordance with the terms and conditions of the policy or contract. If I am not
the owner of any policy or contract identified above, I will not receive advance notice of any change in the
amount of any authorized withdrawal with respect to such policy or contract.
5. The owner of the policy or contract is responsible for ensuring that adequate premiums are paid to keep the
policy/contract in force.

SECTION 6: Signatures (Signature requirements)


All Bank Account Owners must sign this form. Please sign as shown below:
A Partnership The full name of the firm should be printed with the signature of all general partners
(not limited partners).
A Sole Proprietorship The full name of the business should be printed with the signature of the owner
followed by the word “owner.”
A Trust Signatures, followed by the word "Trustee," of all required Trustees. Also submit a
Trust Certification, which is available from your representative, sales office, or the
appropriate number listed under How to submit this form.
A Corporation The signatures and titles of two authorized officers.
An Individual acting on The full name of the Owner's fiduciary or agent and the legal documentation of the
Behalf of the Bank authority to act (e.g., power of attorney, guardianship papers, etc.).
Account Owner

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DEBITAUTH-05 (05/20) Fs/f
By signing this document, I accept the terms of this EPA Agreement.

Print name of Individual signing -


First name Middle name Last name

Title (If you are acting in a representative capacity) Signed at city State

Signature of Owner of the bank account Date (mm/dd/yyyy)

Print name of Individual signing -


First name Middle name Last name

Title (If you are acting in a representative capacity) Signed at city State

Signature of Joint Owner of the bank account Date (mm/dd/yyyy)

Before mailing, please include the following items:


• Banking Routing number, Account number and Bank information • All required signatures • Policy/Contract
Number • Relationships of the Bank Account Owner to the Contract Owner
For sales office use only Sales office/Agency number/Representative ID Date (mm/dd/yyyy)

Sales representative - First name Middle name Last name

SECTION 7: How to submit this form


Return pages 1 through 4 of the completed form to the address or fax number listed below for the Company that
issued the policy or contract. If policies or contracts are issued by more than one Company, return the
completed form to any Company that issued at least one of the policies or contracts.
Contact Phone
Issuing Company Fax Number Address Email
Number
Metropolitan Life Insurance Company 1-800-638-5433 1-908-655-9581 P. O. Box 354, [email protected]
Metropolitan Tower Life Insurance Warwick, RI
Company 02887-0354
Metropolitan Life Insurance Company 1-800-638-5433 1-908-552-3960 P. O. Box 354, N/A
(For Individual Disability Warwick, RI
Income Policies Only) 02887-0354
Annuity contracts issued by any of 1-877-638-3279 1-877-547-9669 P. O. Box 10342 N/A
the Companies listed above Des Moines, IA
50306-0342

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DEBITAUTH-05 (05/20) Fs/f

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