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YES…I WANT TO ENROLL IN THE  DirectPayTM PLAN!

PERSONAL INFORMATION
Name: ________________________________  Policy Number: __________________________
Home Address: _______________________________________________________________________
City/State/Zip: _____________________________________  Home Phone Number: ________________

Deduct from my checking account: Please allow ten business days for initial processing of DirectPayTM 
  Bank Draft (deduction from your checking account ) BE SURE TO INCLUDE YOUR VOIDED CHECK  

        Bank Name_________________________  Account Number___________________________

Please select one of the following payment plans:  The above selected account will be deducted.
 Monthly Withdrawal on the 3rd of each month.
 Monthly Withdrawal on the 15th of each month.
 Bi-Weekly: Please specify initial Friday start date: _____________ (mo/day/year)
 Semi-Monthly: Withdrawals occur on the 15th and the last day of the month.

Please read and sign the following information:
I understand that if my financial institution changes, it is my responsibility to notify GMAC Insurance. I also understand that if GMAC Insurance is no longer able to deduct or charge my premium payments, for any reason, I will then be responsible for making the premium payments. I understand that this request and authorization is voluntary on my part, and that I can terminate it at any time by giving notice.
I hereby authorize GMAC Insurance to initiate a deduction from my designated account and I authorize my financial institution to honor the withdrawal initiated by GMAC Insurance. I understand that this authority remains in effect until DirectPayTM is cancelled in writing by me, GMAC Insurance or the financial institution.

If you fail to make a payment plan selection, we will default to the monthly withdrawal on the 15th of each month.
Signature_______________________________________________________    Date______________

If any automatic payment or credit card charge is returned unpaid by our financial institution for any reason, we may charge you an insufficient funds fee. We reserve the right to change this fee from time to time. Any premium payment received will be first applied to this fee and other outstanding fees due, then to premiums due.
Fax your authorization to us at 1-877-757-4832 or mail it to: GMAC Insurance, P.O. Box 66937, St. Louis, MO 63166-9908.