Electronic Funds Transaction Authorization Send to: Continental American Insurance Company Post Office Box 84075 Columbus, Georgia 31993 Phone: (800) 433-3036 Fax (866) 849-2970 Email: groupclaimfiling@aflac.com I would like to: Start Stop Change direct deposit of my claim payment(s). Account Type: Checking Savings 9-Digit Routing Number: Account Number: Name of Financial Institution: Address: City: State: Zip: Phone: Authorization Agreement for Direct Deposit I authorize Continental American Insurance Company (CAIC) to initiate credit entries, and, if errors occur, I authorize the correction of entries to my account as indicated. This authorization remains effective and in full force until CAIC receives written notification from me of its termination in such time and in such manner to afford CAIC a reasonable opportunity to act on it. Please notify CAIC immediately if your financial institution information has changed by sending notification to the address indicated above. Should you have any questions, please contact us at 1-800-433-3036. Policy/Certificate Holder’s Name (Print): Address: City/State/Zip: Phone #: E-mail Address: Employer Name or Group #: Certificate #: *By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and other materials that CAIC is, or may be, legally required to deliver to you) Policy/Certificate Holder Signature (Required) Note: Forms received without signature will not be processed. Date Signed: ___________________ Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is underwritten by Continental American Life Insurance Company. For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York. Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax **** Please provide a blank voided check or direct deposit form from your financial institution. Incomplete or inaccurate information will not be processed.