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Payment Authorization Form

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Prior to the change being completed, a signed VOID cheque needs to be faxed to (506)450-8691, mailed to our office or e-mailed to your Account Manager. Please allow 14 days for your new bank account information to take effect.

Account Information

By submitting this change, I/we have been provided with details of and understand the terms and conditions of the payment plan by automatic withdrawals from my/our bank account. I/We hereby authorize the above named financial institution to debit my/our account for all payments payable to the above noted insurance company in payment of the insurance premiums and any applicable charges and taxes. I/We understand that this authorization may be cancelled by me/us upon written request.

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