Authorization Agreement for Direct Payments (ACH Debits)

I hereby authorize the third party designee of the appropriate company of the CHUBB Group, including without limitation, Bankers Standard Insurance Company, Pacific Employers Insurance Company, Atlantic Employers Insurance Company, CHUBB Insurance Company of the Midwest, CHUBB American Insurance Company, or Indemnity Insurance Company of North America (any CHUBB affiliate is hereafter the "Company" and collectively, the "Companies")—to initiate on behalf of such Company those debit entries to the checking or savings account(s) with the depository financial institutions indicated above, for the payment of my premium and, if I select recurring payment option, for future premium payments on a recurring basis. I hereby represent and warrant that I am legally authorized to use the bank account(s) that I have specified for the debits being made for such specified amount(s) to the checking or savings account(s) indicated above and that all such transactions to my checking or savings account(s) will comply with all applicable laws of in the United States of America. I understand my insurance may be cancelled if the checking or savings account(s) indicated above do not have sufficient funds to pay the applicable premium or if I contest any recurring debit made under this authorization. All recurring debit entries will show on your bank statement under one of the CHUBB Companies.