DIRECT PAYMENT AUTHORIZATION FORM Please read, sign and return with your Enrollment Forms Name (Last, First, Middle Initial): Phone: Street Address: City: State: Zip: Type of Account: Select Monthly Withdrawal Date:  Savings  Checking  1st  8th  15th Please fill in the below information: Routing Number: Account Number: Confirm Account Number: st Monthly payments are withdrawn on the 1 business day on or after the date you selected above. You will receive a confirmation from Amwins Group Benefits that we have set up your account information to withdraw from your designated bank account. Note: Your monthly deduction will show as Amwins on your bank statement. I authorize Amwins to withdraw my payment as communicated to me, by invoice or letter, from my checking or savings account. I agree to notify Amwins in writing or by phone, if my account information changes or to stop the direct debit authorization at least 10 days in advance of the scheduled transfer. I understand that the premium to be withdrawn may change, in which case I will be notified in writing at least 10 days before the new premium is withdrawn. To the extent I have enrolled in preauthorized checking, I understand that the addition or removal of a dependent will impact the amount withdrawn, and hereby consent to such change. I understand that Amwins will confirm the new preauthorized amount, but depending on when I submit this request, such confirmation may occur after the amounts are withdrawn from my account. If my account is erroneously charged, my financial institution will immediately credit the same amount to the account up to the 15 days following issuance of the statement or 45 days after posting, which occurs first. Signature: Date: Amwins Group Benefits, LLC: 50 Whitecap Drive, North Kingstown, RI 02852