ACH Authorization for Payment Method Storage

I certify that I am an owner or authorized signer for this account.

When I authorize a payment from this account, I authorize Foremost Insurance Company Grand Rapids, Michigan and its affiliates and subsidiaries ("Foremost") to initiate an EFT withdrawal:

• For the policy I select
• For payment of premium in the amount indicated

I also authorize the financial institution where this account is held to honor a withdrawal from this account.

I acknowledge it is my responsibility to have sufficient funds in this account to cover a withdrawal. If there is not, I understand my policy may cancel or expire.

I understand that information stored on Foremost PayOnline^® is kept under physical, electronic or procedural controls that comply with or exceed government standards.

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Use Foremost PayOnline to make a payment on your policy. It's
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