Direct Billing
Information for Intact Insurance Company
Broker
N°
Insured
Send documents to:
Insured
Broker
(If different than instructions previously given by broker)
New debit plan
Policy No(s).
OR
Change of account
Effective Date
Pre-Authorised Payments (Bank debits spread over the policy term)
Short term instalments 2
3
4
Instalments
Date chosen for debits must not be more than 15 days from the effective date.
Changing the date of debit by more than 15 days may lead to an early debit
on renewal.
Ask your broker about this.
Automobile
Home
Business
Date of debits
(ex. the 12th of each month)
Authorization of Payor
I authorize Intact Insurance Company (“Intact Insurance”), and the financial institution designated to begin deductions from my bank account as per my instructions for
monthly regular recurring payments and/or one-time payments from time to time, for payment of all charges arising under my insurance policy (ies) with Intact Insurance and
all fees inherent thereto. I agree to waive a fixed pre-notification period for any change in amount and/or date of debit. I also authorize Intact Insurance to debit my
bank account a fee, as shown on my insurance statement, in the event a debit returns “NSF” regardless of the method of payment. This authorization shall apply to all
insurance policy renewals with Intact Insurance.
This authorization is to remain in effect until Intact Insurance has received written notification from me of its change or termination. This notification must be received at the
address provided below, at least fifteen (15) business days before the next scheduled debit. I may obtain a sample cancellation form or more information on my right to
cancel such an agreement, at my financial institution or by visiting www.cdnpay.ca.
Intact Insurance may not assign or transfer this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing at least
ten (10) business days prior written notice to me.
I have certain recourse rights if any debit does not comply with this agreement. For example, I have the right to receive reimbursement for any pre-approved debit that is not
authorized or is not consistent with this agreement. To obtain a form for a Reimbursement Claim, or for more information on my recourse rights, I may contact my financial
institution or visit www.cdnpay.ca.
Identification of Payor (please print)
Date
Type of service
Last Name
Personal
Financial Institution (FI)
First Name
Business
[attach a sample cheque marked “ Void ”]
FI Account Number
FI Transit Number
(branch – 5 digits, FI – 3 digits)
Address of FI
City
Province
Authorized Signature(s) on FI Account Number
INTACT INSURANCE COMPAGNY
2450 Girouard Street West, Saint-Hyacinthe QC J2S 3B3
Telephone 450 773 9701
58-FL-547.0e (12-10)
Postal Code