Electronic Funds Transfer Plan Authorization Form

Personal Pre-Authorized Debit (PAD) Agreement

Co-operators General Insurance Company

Name of Account Payor Billing Account Number Issue Date Payment Period

MARIAN CAOILE 22369625 25 NOV 2020 EFT Monthly

Policy Number(s):
4001325102 Auto

Financial Institution Information:

Visa Card Number / Expiry Date

(referred to as “EFT Account”)

************1938
03/2021

In this authorization “you” and “your” refer to each holder of the EFT Account who signs this EFT Form.

You authorize us to debit the EFT Account for all amounts owed to us from time to time for all insurance policies
under this bill account. You have read, understand and agree to the terms of the Electronic Funds Transfer Plan
Agreement which forms part of this EFT Form.

The withdrawals from the EFT Account will occur on the 25th day (or next business day) of each payment period.
As of the date of this authorization, the amount to be withdrawn from the EFT Account is approximately
$244.42 per payment period.

___________________ ________________________________________
Date EFT Account Holder’s Signature(s)

___________________ ________________________________________
Date Agent or Service Representative’s Signature

________________________________________
Agent or Service Representative’s Name (please print)

Representative HONG WU
Contact Information: 303-917 85 ST SW
CALGARY AB T3H 5Z9
tel: 403-221-7228

BCEFT/PAD-CGIC (03/2019) Page 1 of 2

Electronic Funds Transfer Plan
Personal Pre-Authorized Debit (PAD) Agreement
1. In this Agreement, “we”, “us”, “our” and “The Co-operators” refer
to Co-operators General Insurance Company and its successors
or assigns, and “you” and “your” refer to each holder of the EFT
Account. “EFT” means a pre-authorized debit withdrawal
pursuant to this Agreement and “EFT Account” means the
account indicated on the Electronic Funds Transfer Plan
Authorization Form (the “EFT Form”) or such other replacement
EFT Account as indicated at any time by you to us.
2. You acknowledge that this Agreement is being entered into for
our benefit and the benefit of any financial institution that holds
the EFT Account (the “EFT Institution”), and is being entered into
in consideration of the EFT Institution agreeing to process EFTs
against the EFT Account in accordance with the rules of the
Canadian Payments Association (CPA). You authorize us to
debit the EFT Account for all amounts owed to us from time to
time pursuant to your insurance policy. You understand that the
amount of the EFT may vary depending on the current cost of
your insurance policy.
3. You understand that a specimen cheque marked “VOID” may be
required, along with the EFT Form (applicable to pre-authorized
chequing only).
4. You warrant to us on a continuing basis that all persons whose
signatures are required to deal with the EFT Account have signed
the EFT Form and that the information set out on the EFT Form
with regard to the EFT Account is accurate and complete.
5. You acknowledge that the EFT Institution is not required to verify
that each EFT submitted by us has been issued in accordance
with this authorization, including, but not limited to, the amount, or
that the purpose of payment for which the EFT was submitted has
been fulfilled by us as a condition of honouring the EFT.
6. You have certain recourse rights if any debit does not comply with
this agreement. For example, you have the right to receive
reimbursement for any debit that is not authorized or is not
consistent with this Pre-Authorized Debit (PAD) Agreement. To
obtain more information on your recourse rights, contact your
financial institution or visit www.payments.ca.
7. We will not transfer the right to debit your EFT account to any
other organization.
8. You may cancel this authorization at any time by providing us ten
(10) days prior notice, either by calling or visiting your Agent or
Sales Representative’s Co-operators office. For a sample
cancellation form or for more information on your right to cancel a
Pre-Authorized Debit (PAD) Agreement, contact your financial
institution or visit www.payments.ca.
9. Cancellation of this authorization does not terminate your
insurance policy or relieve you of any obligation to pay all
amounts owing to us on your insurance policy by a method of
payment that is satisfactory to us. This authorization applies only
to the method of payment and does not otherwise affect your
obligations to us. Cancellation of your insurance policy does not
automatically terminate this authorization. Unless terminated on
notice as set out above, this authorization will remain in effect
until all amounts owed by you to us in respect of your insurance
policy have been paid.
10. You consent to allow us to use the personal information on the
EFT Form for the purpose of implementing this Agreement, it
being understood that such use will conform to our privacy policy.
Our privacy policy is posted on our website at
www.cooperators.ca. A copy is also available from your Agent or
Service Representative.
BCEFT/PAD-CGIC (03/2019)
11. You undertake to notify us of any changes to your EFT Account
information, providing us ten (10) days notice before the next
withdrawal date of your EFT to ensure that your insurance
coverage is not interrupted. This includes changes to your
financial institution branch and/or bank account number, or credit
card number and/or card expiry date where applicable.
12. You understand that should your down payment be returned for
non-sufficient funds (“NSF”) or is declined, the policy to which this
premium applies will be subject to cancellation and we will charge
you a $25.00 service fee. You may no longer qualify for our EFT
plan.
13. You understand that if at your regular withdrawal date, your
payment is returned for non-sufficient funds (“NSF”) or is
declined, we will re-attempt to debit the same withdrawal amount
again approximately seven (7) days later. If at that time, funds
are available in your account, your insurance coverage will
continue uninterrupted. We will charge you a $25.00 service fee
at your next withdrawal date of your EFT. Repeated NSF
payments may disqualify you from the EFT plan. If that happened,
you would be sent an invoice for the full amount remaining for the
rest of your policy term.
NOTE: If at the second withdrawal attempt your payment is
returned for non-sufficient funds (“NSF”) or is declined, the
policy to which this premium applies will be subject to
cancellation and we will charge you an additional $25.00
service fee. You may no longer qualify for our EFT plan.
When reapplying for insurance coverage, past due service
fees will be applicable.
14. You understand that your EFT amount may increase or decrease
when the actual policy premium is determined, or if policy
changes are made, or if the premium for the renewal of any policy
should change, or if a service fee has been charged. Any
decrease in premium resulting from changes made mid-term will
be applied to any balance owing on your bill account.
15. You understand when your EFT amount changes, you will be
notified in writing and/or will be verbally informed by your Agent or
Sales Representative. If notified in writing, the pre-notification will
be sent to you by regular mail ten (10) days before the next
withdrawal date of your EFT.
16. You understand that an EFT service fee may apply to this EFT
Plan where applicable.
17. For inquiries or questions about your Agreement, please contact
your Co-operators Agent or Sales Representative.
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