CHECKING ACCOUNT AUTHORIZATION OF FUNDS FORM

ATTENTION: Please email the completed form to Support@EZMedicaidApps.com or fax it to 888-245-5834 (please begin your fax immediately). Please DO NOT MAIL ANY FORMS or CHECK once you have emailed or faxed the information. When emailing the COMPLETED form, kindly attach a check (a voided check is acceptable). The check does not need to be made out to UNITY. Please ensure that the routing and account numbers are clearly visible and unobstructed.

Insured Name

This form can be used to authorize either a single withdrawal or to activate a recurring series of Pre Authorized Checking (“PAC”) payments. I hereby authorize Unity Financial Life Insurance Company to draw an electronic fund transfer (“EFT”) from my checking account for payment of life insurance. By signing this form, I authorize Unity Financial Life Insurance Company to initiate an EFT from my bank account according to the terms of the attached check. I understand that my check will be converted to an electronic transaction. I am aware that my checking account may be debited the same day Unity Financial Life receives my email or fax.

Single Payment Option

Please enter your initials below to authorize Unity Financial Life Insurance Company to process a ONE-TIME electronic funds transfer (EFT) from your checking account for payment of your new life insurance policy.
By entering the amount above, you authorize a one-time immediate withdrawal from your account. Please ensure the amount entered is a whole number (no decimals).
Type

Please enter today's date below:

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When emailing the COMPLETED form, kindly attach a check (a voided check is acceptable). The check does not need to be made out to UNITY. Please ensure that the routing and account numbers are clearly visible and unobstructed.

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