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AAA Auto Pay Plan Terms and Conditions The Authorization Agreement at the bottom of this page is valid only for insurance policies written by the Interinsurance Exchange of the Automobile Club("Exchange")and for your AAA membership.* Automatic debits from your checking account for insurance policies will begin with the first AAA Auto Pay Plan payment billed after the Authorization Agreement is received and processed. (Please allow 15 days for processing.) Until then,your insurance premium payment is still due on the date shown on your most recent billing statement and should be returned to us in the white envelope provided. Outstanding membership dues amounts will begin to be debited after the Authorization Agreement has been processed. AAA Auto Pay automatic payments are subject to all applicable finance charges,installment and other fees. Insurance only: We gave you notice of the amount of all applicable finance charges and fees at the time you applied for the insurance policy(ies)below and upon renewals of your policy(ies). Installment payment plans and all fees are subject to change without notice. Policyholders and members who have payments returned unpaid from their financial institution may have the AAA Auto Pay Plan authorization revoked as to all insurance policies by the Exchange and as to AAA membership by Automobile Club of Southern California("AAA"). In the event that this occurs,you will be notified by mail and a return payment fee and late fee may be added to your bill(or to a second attempted debit to your account). If AAA Auto Pay is revoked, g installments remaining for the current insurance policy period will be billed on your regular payment plan with statements mailed to you and outstanding membership dues and fees will be billed with statements mailed to you periodically. If an error is made,the Exchange or AAA,as applicable,can correct it by initiating debits or credits. You may revoke enrollment in the AAA Auto Pay Plan,as to any one or more insurance policies and/or your membership,at any time by signing and dating a written request and mailing it to: AAA/Interinsurance Exchange of the Automobile Club,P.O. Box 25006,Santa Ana,CA 92799-5006. While not required,a revocation form is available for your use at AAA.com/form or upon request by contacting us at 1.800.924.6141 or your local AAA branch. * If you enroll in AAA Auto Pay for more than one insurance policy and/or membership,the processing bank will determine the order of processing debits (I.e.,the order of payment)for each policy and/or membership. If you would like to make payments out of more than one checking account,you will need to complete one Authorization Agreement for each checking account. If you would like to enroll more than three insurance policies in AAA Auto Pay,please use one Authorization Agreement for every three policies. Your current payment is still due on the date shown on your most recent billing statement and should be returned to us in the envelope provided. nor S SMITH ; IANE M S,M1111 MtU00 LOS PLACE ST SAMPLE ��—IIXI'IVUTON BEACH CA 92647 Date Mail completed forms with a voided check (optionap — _ Or r�,nr_• C I�L� i. in the envelope provided, or return to: _. Doll.- AAA/Interinsurance Exchange of the Automobile Club �vz H�„ti costa M—.CA 926IN' P.O. Box 25006 Santa Ana, CA 92799-5006 • 215 111 1! 21S 0 Important: This form cannot be faxed or electronically mailed to us. We must have an original signature to complete this transaction. Please keep a copy of this form for your records. ACH0809A.E211201208 PX4 1112424 JVI Please detach at line. AUTHORIZATION AGREEMENT FOR INSURANCE AND MEMBERSHIP DIRECT PAYMENTS(ACH DEBITS)—AAA Auto Pay Plan • To use AAA Auto Pay for your membership, enter your Club Code and Membership Number in the boxes below. • Please enter the number of each insurance policy you want billed through AAA Auto Pay. Club Code First A Di;ts of Membershi Number Lefler Prefz up to 3 MEMBER# ❑�_�❑�❑❑� POLICY# ©�� oo®a©®®a© Letter Prefix(up l03 ❑❑❑❑❑❑❑�❑ POLICY# L❑etter Preto upt� ❑❑❑❑❑❑❑❑❑ POLICY# I(we)hereby authorize the Interinsurance Exchange of the Automobile Club("Exchange')and Automobile Club of Southern California("AAA'),to initiate debit and credit entries to my(our): CHECKING ACCOUNT indicated below at the financial institution named below("Institution'),for(i)all amounts that become due by me(us)to the Exchange,including,without limitation,insurance premium,finance charges,installment,return payment,late payment and other fees("Fees'), (ii)all membership dues that become due by me(us)to AAA and all related Fees,and to debit that same to such account. I(we)acknowledge that the origination of ACH transactions to my(our)account must comply with the provisions of U.S.Law and is governed by the Terms and Conditions that accompanied this Agreement. INSTITUTION NAME Must be exactly 9 digits Up to 17 digits ROUTING#[]❑❑❑[:]❑❑❑❑ACCOUNT#[:]❑❑❑❑��E❑❑[—]❑F]❑ E][7] This authorization is to remain in full force and effect until terminated by the Exchange or AAA or until the Exchange or AAA has received written notification from me(or either of us)of its termination in such time and in such manner as to afford,the Exchange or AAA,as applicable,and Institution,a reasonable opportunity to act on it. NANIE(S)OF ACCOUNT IIOLDER(S) DATE SIGNATURE(S)OF ACCOUNT HOLDER(S) AAA Employee#(ifappucable) Branch/Sec It Membership# Alerober Name 8417(3t13)