AUTHORIZATION AGREEMENT FOR PRE-AUTHORIZED PAYMENTS

Name(s)

Bank Name

Transit Number

Bank Checking Account Number

Pre-Authorized Amount

I (we) hereby authorize Berkley Risk Services to initiate electronic debit entries to the account I (we) have in the financial institution named above and authorize the financial institution to honor these entries and debit my (our) account. I (we) understand that Berkley Risk Services will provide timely notice of any change in my (our) payment amount and will deduct the new amount when it becomes effective. I (we) also understand that I (we) may cancel this authorization by notifying Berkley Risk Services in writing at least 10 days prior to the next automatic payment. I (we) will provide 10 days prior notice to Berkley Risk Services of my (our) intent to cancel any policy which is drafted under this agreement and agree that Berkley Risk Services is not liable for any payments that have been made on my behalf. I (we) agree not to hold Berkley Risk Services liable for any loss of coverage which may result from the failure to draft or otherwise collect premiums, whether the cause be due to insufficient funds, bank error, or other processing error.

Signature	Date
Co-Signature (if required)	Date

Just complete this form and return it with a void check for the affected account. After that we will draft the payment from your account between the 20th and 25th of each month. Your bank will show the payment on your monthly bank statement. Berkley Risk Services will send you a quarterly statement which will show your automatic payments for the last quarter.

Please call Berkley Risk Services at 303-357-2608 or 877-502-0108 with any questions you may have.

PLEASE PRINT, COMPLETE, SIGN & RETURN THIS FORM WITH A VOID CHECK BY THE 10TH OF THE MONTH PRIOR TO THE FIRST DRAFT		BRSC Use Only Cust # Prenote Draft
Mail to: Berkley Risk Services of Colorado 2000 South Colorado Blvd Annex Building, Suite 410 Denver, CO 80222	Fax to: Berkley Risk Services of Colorado 303-357-2626