Bmo Authorization Form – Fill Out and Use This PDF

BMO Life Assurance Company

60 Yonge Street, Toronto, ON M5E 1H5

1-800-387-9855 Fax: 416-362-6845

REQUEST FOR PRE -AUTHORIZED P AYMENT

Automatic monthly withdrawals from your bank account

FOR POLICY NUMBER:

I/We authorize BMO Life Assurance Company to debit the account below to pay premiums, including overdue premiums, for the above numbered policy(ies) and any other policy(ies) I/We designate, on the _________ day of each month or the next business day.

		Attach a sample Cheque marked “VOID”
NAME OF
PAYOR:		(please print)
NAME OF FINANCIAL INSTITUTION:
ADDRESS OF FINANCIAL
INSTITUTION:
BRANCH					ACCOUNT
NUMBER:					NUMBER:

Declaration:

I/We have chosen to make payments of premium using the Pre-Authorized Debit Plan and agree to the following: I/We agree that, for the purpose of this agreement, all pre-authorized debits (PADs) will be treated as personal. I/We waive the right to receive 10 days pre-notification prior to my/our first debit and any changes to the amount of each PAD or of any change to the payment date of the PAD. I/We acknowledge and agree that the premium payment will be paid by a PAD that you will process in accordance with the terms of the policy. The premiums will be paid by PADs that you will issue (i) on the recurring deduction date I/We have chosen or

(ii)if I/We have not chosen an eligible deduction date, on the recurring premium due date specified in my/our policy.

I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/We have the right to receive reimbursement for any debit that is not authorized or is not consistent with this PAD agreement. To obtain more information on my/our recourse rights, I/We may contact my/our financial institution or visit cdnpay.ca.

I/We may revoke my/our authorization at any time, upon providing 30 days notice, in writing, to BMO Life Assurance Company at the address shown above. I/We understand that I/We may obtain a sample cancellation form or further information on my/our right to cancel a PAD agreement at my/our financial institution, by contacting BMO Life Assurance Company or by visiting cdnpay.ca. If I/We require more information or have an issue regarding my/our PAD agreement with BMO Life Assurance Company, I/We understand that I/We may contact you at 1-800-387-9855.

DATE:		/		/
	Day		Month		Year		Signature of Payor(s)

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