Credit Card Authorization Form
Form to be used only for the collection of
initial insurance premium on Term, Whole
American General Life Insurance Company Life, and Accident & Health Products Only
Please read this authorization carefully and complete all requested items.
Type of Insurance/Contract Applied For: ____________________________________________________________________
Policy Number: ____________________________________________________________________________________________
Name of Proposed Insured: ________________________________________________________________________________
Proposed Policy Owner:____________________________________________________________________________________
Cardholder Name: (exactly as it appears on the card) ________________________________________________________
Cardholder Billing Address: ________________________________________________________________________________
__________________________________________________________________________________________________________
Credit Card Number:_________________________________________________ Expiration Date: ______________________
Card Type: American Express® MasterCard® Visa®
Quoted Initial Premium Amount: _________________________
I authorize and request the Company and/or its representative to charge the credit card listed above for the Quoted
Initial Premium Amount. I understand and agree that:
1) If there are no changes to the policy as applied for, the charge to the account for the Quoted Initial Premium
Amount will be processed when the Company places the policy in force.
2) In the event of changes to the policy as applied for, any new Initial Premium Amount will be communicated
to me. If I accept that change, the charge to the account for the new amount will be processed when the
Company places the policy in force.
Any information gathered may be disclosed to any person or entity required to receive such information by law or
as I may further consent.
I understand and agree that this transaction is subject to the acceptance by, and the terms and conditions of, the
credit card company indicated above. I understand and agree that this Authorization Form is not a part of the
application or policy of insurance applied for and does not modify any terms or conditions contained therein.
I understand and agree that the Company shall incur no liability if the credit card company dishonors any amount
charged under this Authorization and may terminate this Authorization immediately if any charges are not paid.
I agree to hold the Company harmless from any and all costs, claims, or causes of actions arising from or related
to this authorization. I authorize the Company to obtain information and/or reports from a consumer reporting
agency or other company(ies) in order to verify, validate and/or authenticate the information and answers
presented on this form. I understand and agree that payment of the initial premium is one of the conditions
required for coverage to be placed into effect. If the charge is declined for any reason, I understand and agree that
coverage will not be placed into effect.
Name of Authorized Person (printed):___________________________________________ Date ______________________
For Internal Use Only
#: ________________________________________________ Date: _________________________________________________
Signature of Authorized Person on Account
X
Signed on (date) ______________________________________
Please return this copy with the application. AGLC100949 Rev0215
Credit Card Authorization Form
Form to be used only for the collection of
initial insurance premium on Term, Whole
American General Life Insurance Company Life, and Accident & Health Products Only
Please read this authorization carefully and complete all requested items.
Type of Insurance/Contract Applied For: ____________________________________________________________________
Policy Number: ____________________________________________________________________________________________
Name of Proposed Insured: ________________________________________________________________________________
Proposed Policy Owner:____________________________________________________________________________________
Cardholder Name: (exactly as it appears on the card) ________________________________________________________
Cardholder Billing Address: ________________________________________________________________________________
__________________________________________________________________________________________________________
Credit Card Number:_________________________________________________ Expiration Date: ______________________
Card Type: American Express® MasterCard® Visa®
Quoted Initial Premium Amount: _________________________
I authorize and request the Company and/or its representative to charge the credit card listed above for the Quoted
Initial Premium Amount. I understand and agree that:
1) If there are no changes to the policy as applied for, the charge to the account for the Quoted Initial Premium
Amount will be processed when the Company places the policy in force.
2) In the event of changes to the policy as applied for, any new Initial Premium Amount will be communicated
to me. If I accept that change, the charge to the account for the new amount will be processed when the
Company places the policy in force.
Any information gathered may be disclosed to any person or entity required to receive such information by law or
as I may further consent.
I understand and agree that this transaction is subject to the acceptance by, and the terms and conditions of, the
credit card company indicated above. I understand and agree that this Authorization Form is not a part of the
application or policy of insurance applied for and does not modify any terms or conditions contained therein.
I understand and agree that the Company shall incur no liability if the credit card company dishonors any amount
charged under this Authorization and may terminate this Authorization immediately if any charges are not paid.
I agree to hold the Company harmless from any and all costs, claims, or causes of actions arising from or related
to this authorization. I authorize the Company to obtain information and/or reports from a consumer reporting
agency or other company(ies) in order to verify, validate and/or authenticate the information and answers
presented on this form. I understand and agree that payment of the initial premium is one of the conditions
required for coverage to be placed into effect. If the charge is declined for any reason, I understand and agree that
coverage will not be placed into effect.
Name of Authorized Person (printed):___________________________________________ Date ______________________
Signature of Authorized Person on Account
X
Signed on (date) ______________________________________
Applicant: Please retain this copy for your records. AGLC100949 Rev0215
