I hereby authorize Canadian Benefit Administrators Ltd. to make automatic withdrawals for my insurance premiums, from my account at the financial institution named below.
I understand that premiums will be withdrawn on the fifteen of each month. Your monthly billing statement will indicate how much money will be withdrawn and is always sent in advance.
Further, I understand that Canadian Benefit Administrators Ltd. will terminate my pre-authorized payment plan if any withdrawal is reversed by my financial institution.
This form authorizes Canadian Benefit Administrators Ltd. to charge a fee for any pre-authorized payments not honored by my financial institution.
This agreement will remain in effect unless I send Canadian Benefit Administrators Ltd. a written notice of cancellation or until I submit a revised pre-authorized withdrawal form. This notification must be received ten (10) business days before the next withdrawal is scheduled.
I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any withdrawal that is not authorized or consistent with the Agreement. To obtain a form for a Reimbursement Claim or for more information on my recourse rights, I can contact my financial institution or visit www.cdnpay.ca.