AutoPay Authorization Agreement

Effective Date: 01/21/2018

Credit Card Authorization

I hereby authorize Amica to initiate charges to the credit card account indicated on this page. This authorization applies to the listed policies and their renewals. This authority is to remain in full force and effect until Amica has received notification from me in such time and in such manner as to afford Amica a reasonable opportunity to act on it.

Bank Account Authorization

I hereby authorize Amica to initiate debit and/or credit entries to the bank account indicated on this page and the depository identified on this page hereinafter called DEPOSITORY, to debit and/or credit the same such account. I acknowledge that the origination of ACH transactions to my bank account must comply with the provisions of U.S. law. This authorization applies to the listed policies and their renewals. This authority is to remain in full force and effect until Amica and DEPOSITORY have received notification from me in such time and in such manner as to afford Amica and DEPOSITORY a reasonable opportunity to act on it.

This authorization may be cancelled at any time by logging on to your account on Amica.com and editing your settings to remove policies or cancel your enrollment, or contacting an Amica representative at 800-242-6422.