(iene & REQUEST FOR PRE-AUTHORIZED PAYMENT PLAN for account: I hereby authorize State Farm Mutual Automobile Insurance Company, its affiliates and subsidiaries, to deduct insurance payments or loan repayments from my account at the financial institution named below. Financial Institution WELL © ARGS Select one: Chequing Account - Please submit a voided or photocopied cheque with authorization. Gi Savings Account - Please submit a volded or photocopied depostt slip with authorization. i Credit Union Share Draft Account - Please submit a voided or photocopied check with authorization. Ifthe voided cheque or deposit slip does not include a transit or account number, please obtain this information from your financial institution and submit with authorization. This authority is to remain in effect until State Farm® has received written notification from me ofits termination in such time and in such manner as to afford State Farm and the Depository institution @ reasonable opporturity to act on the request. ‘State Farm has the right to discontinue the Pre-Authorized Payment Plan if any two or more deductions are not honored, State Farm will notify me in advance whenever the deduction amount or the day changes. Hany deduction is not honored by my Financial Institution, the policies or loans will be considered not paid. State Farm will ask me to pay the dishonored amount. After timely payment is received by State Farm, deductions will resume. | understand and agree State Farm has no obligation to and will not apply any loan repayment amount toward any premium which is unpaid. State Farm may revise the terms of this agreement at any time upon written notification. | have also received the State Farm Payment Plan Agreement. Requested Deduction Day 1st through 28th (If different than current due date.) 78 Ger) Vecw Ae Cor Fant Name of State Farm Payment Plan Accountholdar Paul A. Ror _ shoots yc" /NdS_ 2016 STATE FARM AFFILIATE INSURERS ‘The type of payment plan and the state in which the insured lives will determine which of the State Farm affliates will initiate the pre-authorized debit. An insured may have a pre-authorized agreement with more than one State Farm affiliate for different premium payment plans. ‘The State Farm affiiate insurers are: STATE FARM MUTUAL AUTOMOBILE INSURANCE COMPANY ‘STATE FARM FIRE AND CASUALTY COMPANY STATE FARM GENERAL INSURANCE COMPANY STATE FARM LIFE INSURANCE COMPANY STATE FARM LIFE AND ACCIDENT ASSURANCE COMPANY STATE FARM INDEMNITY COMPANY STATE FARM LLOYDS STATE FARM COUNTY MUTUAL INSURANCE COMPANY OF TEXAS STATE FARM FLORIDA INSURANCE COMPANY: STATE FARM INTERNATIONAL LIFE INSURANCE COMPANY LTD. 492250.1 0626-2007 Page t of2eT = oem PAUL A ROTH 2133, 908 Né 38RD AVE e260 gen VANCOUVER, WA 86682-2026 Se pavToTHe SmDEROF , EZ = 12423008800) SO25S3572ba O2n3a3