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American Century Life Insurance Company
9120 South Toledo Avenue
Tulsa, OKlahoma 74137
Office 918-712-7770
Fax 918-712-7773
Credit Card Authorization
This form gives American Century Life authorization to debit entries to your credit card account each month to pay your premiums.
I (we) hereby authorize American Century Life Insurance Company hereinafter called Company, to initiate debit entries to my (our) Credit Card account to be drafted each month.
Name of Insured .
Policy Number
Name on Card
Amount to be drafted
Date of Draft 5th of the month 20th of the month
Type of Card Mastercard Visa
Account Number
Expiration Date Security Code on Back
Billing Address
City, State and Zip
Phone Number
This authority is to remain in full force and effect until Company and Bank has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Company and Bank a reasonable opportunity to act on it. I (or either of us) has the right to stop payment of a debit entry by notification to Bank as such time as to afford Bank a reasonable opportunity to act on it prior to charging account. After account has been charged, I have the right have the amount of an erroneous debit immediately credited to my account, be depository, provided I (we) send written notice of such debit entry in error to bank within 15 days following issuance of the account statement or 45 days after posting whichever occurs first.
Dated ________________________________________________________________________________________________________
Print Name____________________________________________________________________________________________________
Signature______________________________________________________________________________________________________
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