PAC Form Canada Life
PAC Form Canada Life
PAC Form Canada Life
To: The Canada Life Assurance Company (“Canada Life”) and my Bank (the Canadian financial institution I designate now
or subsequently)
I, the Bank ACCOUNT HOLDER, request and authorize the Canada Life to make monthly withdrawals from my account specified
below, or any account of mine I subsequently designate. I authorize and agree that my Bank may deal with each such withdrawal
as though it was signed by me, and need not verify that the withdrawals are in accordance with this authorization. For any joint
account, I certify that all persons required to sign on this account have done so. It is further understood and agreed that:
1. This authorization is for the withdrawal of the monthly premium payments established for the policy/ies I designate now or
subsequently, and may include any agreed policy loan repayments. If the first withdrawal request in a month is not honoured
because of insufficient funds (NSF), Canada Life may make another withdrawal request.
Please make withdrawals from the Bank (Canadian Financial Institution) designated on the sample cheque attached.
DEPOSITOR’S NAME PLEASE PRINT