I hereby authorize the appropriate third party designee of the applicable company of the CHUBB Group—including without limitation, Bankers Standard Insurance Company, Pacific Employers Insurance Company, Atlantic Employers Insurance Company, CHUBB Insurance Company of the Midwest, CHUBB American Insurance Company, or Indemnity Insurance Company of North America (any CHUBB affiliate is hereafter the "Company" and collectively, the "Companies")—to initiate on behalf of such Company those debit entries to the checking or savings account(s) with the depository financial institutions indicated above, for the payment of my premium and, if I select recurring payment option, for future premium payments on a recurring basis. I hereby represent and warrant that I am legally authorized to use the bank account(s) that I have specified for the debits being made for such specified amount(s) to the checking or savings account(s) indicated above and that all such transactions to my checking or savings account(s) will comply with all applicable laws in the United States of America. I understand my insurance may be cancelled if the checking or savings account(s) indicated above do not have sufficient funds to pay the applicable premium or if I contest any recurring debit made under this authorization. All recurring debit entries will show on your bank statement under one of the CHUBB Companies.
The withdrawal entry will be the total amount of the invoice for the insurance premium due at the beginning of the payment period. Any issues, objections, or discrepancies regarding the amounts invoiced must be reported in writing to the Company no later than 15 days from the invoice date. If a withdrawal entry is returned and no other provision is made for payment on or before the due date, then payment will be considered delinquent pursuant to the terms and conditions of related insurance agreements. I understand that if there is a change to my checking or savings account information, I must sign in to my account at www.chubb.com and update the enrollment information in order to ensure the payment will process successfully. I understand that the Company may terminate this agreement upon prior written notice to me, which may be delivered by e-mail or other electronic means. I understand that my authorization for storing my payment and related information and/or initiating withdrawals from my depository accounts will remain in full force and effect until I provide notice to Company of termination of my authorization, which can be provided by me by signing into my account at www.chubb.com and unenrolling from AutoPay.