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I hereby authorize TMA Insurance Trust, to automatically debit payment from my bank as indicated above. TMA Insurance Trust will note the transaction as a pending payment until all funds are secured from my bank or banking institution. In the event TMA Insurance Trust is unable to secure funds from my bank account for any reason, including but not limited to, insufficient funds in my account or insufficient or inaccurate information provided by me when I submit this electronic payment authorization, further collection action may be undertaken by TMA Insurance Trust including application of returned check fees to the extent permitted by law.
By my signature below, I authorize TMA Insurance Trust in accordance with the Agreement, to charge my back account for the amount of my insurance contribution payment until such time, I provide a written notice of cancellation or my insurance is terminated.
