I hereby request Pioneer Pacific Consultants, Inc. dba PIOPAC Fidelity to draft my payment card or bank account, in the amount shown above or an amount greater of up to 20% in the event carrier product increases rate of premiums at renewal, and to receive notices of premiums due via email, text message, and/or phone call on policies for which I have made application. This authorization shall remain in effect until written notice is provided to PIOPAC Fidelity by me to discontinue them. This authorization is not dependent upon my employment or membership terminate. In consideration of the honoring of my request, I understand and agree to the following conditions: 1) Drafts shall be made as scheduled. 2) Drafts will include the per cycle administrative fee indicated above. 3) If any charge is not honored on presentation and if any premium is not paid, the policy(ies) may lapse in accordance with its terms and 4) there is a reprocessing fee of $25 assessed on all returned ACH Drafts, $15 for declined credit/debit card monthly withdraw on my draft account and a $25 Non-Negotiable Fee for any/all ACH, Debit/Credit Card Disputed Charges5) PIOPAC Fidelity, Inc. may automatically revoke this Authorization if any charges are not paid on presentation. 6) This Authorization shall not be construed as a modification of any of the provisions of the policy(ies). 7) The Insurer, the Premium Payor or the Bank may cease Authorization by giving 10 days’ written notice to PIOPAC Fidelity. 8) If the Authorization is revoked, premiums falling due thereafter may be payable directly to the insurer. 9) In the event of a dishonored draft, I authorize Pioneer Pacific Consultants, Inc. dba PIOPAC Fidelity to contact me via email, text, telephone, or combination.
I hereby authorize PIOPAC Fidelity to initiate debit entries electronically to my account indicated above and I authorize the depository institution named above to debit same to such account. These authorizations remain effective and in full force until PIOPAC Fidelity has received written notification from me of its termination in such time and in such manner to afford PIOPAC Fidelity and the depository/institution a reasonable opportunity to act on it