Policy #

GBL-059 (091714) S, 1, N, N, N, A

Aspire General Insurance Services‐ CA Lic#: 0I10876

UNDERWRITTEN BY ASPIRE GENERAL INSURANCE COMPANY

AUTOMATIC MONTHLY PAYMENT AUTHORIZATION (EFT)

I authorize Aspire to initiate scheduled deductions from the bank account identified below for payment of premium on the insurance policy issued to me and any

renewals thereof.

I authorize the financial institution identified by the routing number below to accept the post entries to the account.

I represent that I am the owner and/or an authorized signer of the account.

I understand that this authorization allows Aspire to adjust the scheduled deductions to reflect any premium changes to my policy. Aspire agrees that it shall notify

me in writing at least ten days prior to making any deduction if there is a premium change or seven days if there is a due date change. Please note that although

payment will typically be processed on the Withdrawal Schedule dates, please allow several days for processing of the withdrawals from your account.

Additionally, that Aspire may electronically withdrawal or create a draft against your account.

I understand that Aspire will not send me a bill before scheduled deductions are made and that it is my responsibility to ensure sufficient funds are in the account

at the time of each scheduled deduction.

I also understand that my policy may cancel or expire if there are insufficient funds in the account, which could cancel this agreement and remove my policy from

automatic payment processing. In addition to any fees charged by my bank, Aspire will charge a return item fee of up to $25.00 if my payment is dishonored or

returned for any reason. Additionally, you will be removed from the Automatic Monthly Payment Authorization program.

This authorization is to remain in full force and effect until Aspire receives a written request from me to cancel my electronic payment withdrawal or until Aspire

elects to cancel this agreement.

PLEASE NOTE THAT THE CHARGES WILL APPEAR ON YOUR BANK STATEMENT AS "ASPIRE." IF YOUR DUE DATE FALLS ON A WEEKEND OR

HOLIDAY WE WILL MAKE THE PAYMENT ON THE NEXT BUSINESS DAY FOLLOWING THE HOLIDAY/WEEKEND.

Please allow up to 7 days for changes or termination of electronic payment withdrawal to ensure changes are made prior to the withdrawal of your installment.

If you have any questions or concerns about this transaction, you can email accounting@agicins.com or call Customer Service at (877) 789-4742.

All the information requested below is required and very important for the accurate processing of your automatic monthly withdrawal payment plan. If any of the

information is missing or inaccurate, please be aware that this may delay the processing.

Please note that your monthly withdrawn payments are subject to change depending if any changes that cause an increase or decrease to your written premium

are made to the existing policy during the term.

Named Insured

________________________________

Policy #

_________________________________________

Account Holder

Phone #

Payee Address

Routing #

________________________________________________

Account #

_____________________________________________

Type

________________________________________________

Account Holder Signature

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PLEASE ATTACH VOIDED CHECK HERE, CHECK REQUIRED