American Heritage Life Insurance Company

1776 American Heritage Life Drive

Jacksonville, Florida 32224

CLAIMS ADMINISTRATION DIRECT DEPOSIT AUTHORIZATION FORM

TRANSACTION TYPE: New Setup Cancellation Change Financial Institution Change Account Number

POLICY/CERTIFICATE HOLDER INFORMATION:

Policy/Certificate Holder Name: Home Phone:

Policy/Certificate Number(s):

Social Security Number:

FINANCIAL INSTITUTION: Checking Savings

Financial Institution Name:

Financial Institution Address:

Account Number: *Electronic Routing Transit Number:

*Some banks use a separate routing number specifically for electronic ACH deposits. Please verify the routing number with your bank.

A Voided Check or a Letter From Your Bank Must be Attached In Order to

Credit Your Account for Claims Payments

Voided Check Requirements: Bank Letter Requirements: Acceptable Accounts and Signatures:

- Deposit slips are not accepted; - Letter must be on bank letterhead; - Policy/Certificate Holder

- Credit and debit cards are not accepted; - Include Account holder’s name; - Power of Attorney

- Account holder’s pre-printed name and address; - Include Account holder’s account number: - Beneficiary

- Pre-printed account and transit number. - Include Account holder’s transit number.

AUTHORIZATION AND SIGNATURE:

I authorize American Heritage Life Insurance Company (AHL) to initiate credit entries to the account number shown above for claims

payment for all of my AHL policies (unless benefits are assigned). I understand that AHL will make any adjustments, including the

initiation of any credit or debit entries on the account, for the limited purpose of claims payment due to the account holder or due to

AHL. Subject to local laws, AHL reserves the right to recover any credit entries made to my account in error.

Signing this Authorization will allow AHL to deposit claims payments for all eligible policies underwritten by AHL, excluding Life.

Although direct deposit (Electronic Funds Transfer) is my preferred method of payment there may be circumstances which require a

paper check to be issued as opposed to a direct deposit. I understand when I do business with AHL and/or its affiliates, parent and

subsidiaries, the electronic documents, disclosures and electronic signatures may be utilized by AHL. This authority is to remain in full

force and effect until AHL has received written notification revoking the authority. The financial institution information above is complete

and accurate and is that of the policy/certificate holder on file (unless the policy/certificate holder is incapacitated or deceased). I

understand I must notify AHL immediately if my financial institution or account information has changed by sending written notification

to the address indicated below.

Policy/Certificate Holder Signature: Date:

Deliver the completed and signed authorization form with voided check or bank letter to:

Fax to: 1-866-424-8482 OR Mail to: Allstate Benefits

Attention: Claims ACH Department

1776 American Heritage Life Drive

Jacksonville, FL 32224-6687

Should you have any questions, please contact us at 1-800-348-4489.

ABJ16661-2 (3/17)