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Disclosure to Cardholder and Cardholder Consent

Terms of Agreement for Monthly Payment Plan

I, the cardholder, authorize Pembridge Insurance Company (“Pembridge”) and its affiliates and the credit/debit card issuer for the specified card to charge my payment card or the card I, or my credit/debit card issuer, replace it with. Pembridge will retain my credit/debit card details for as long as the stated policy remains in effect or until I contact Pembridge to arrange an alternate method of payment.  I understand that my credit/debit card issuer can supply Pembridge with updated expiration date and/or card number, however it is my responsibility to update Pembridge when the card and/or expiration date on the card changes.  If a charge is returned unpaid and payment is not made, Pembridge will issue a cancellation notice for non-payment of premium and initiate an amount owing status on the policy.  I have the valid payment card as specified and for all charges have available credit to accept such charges.  Charges to the monthly payment plan shall be initiated by Pembridge to pay premium,  other charges and fees, including, if applicable, any fee charged after the policy’s termination effective date, for, or as associated with, the stated policies or other policies as authorized, and the charge entries shall constitute my receipt for the transaction(s).  No payment to Pembridge shall be deemed to have been made unless and until Pembridge receives payment.  I also understand that if corrections to charges are necessary, it may involve an adjustment to the monthly payment plan.  I understand the charge to my payment card of the billing schedule amount will be charged on or after the premium due date indicated on the schedule and that I should continue to pay any bills I am sent prior to receiving the schedule.   I understand that Pembridge can create a one-time charge at my authorization.  I understand that I will thereafter be sent a payment schedule only at renewal or if the premium amount changes during the policy period.  Pembridge reserves the right to refuse or terminate automatic payment services.  This agreement is to remain in effect until Pembridge terminates it or until I contact my Broker to request termination. Pembridge may require up to five (5) business days to act on my request.  Should a policy or monthly payment plan be subsequently offered by an affiliate company of Pembridge, I understand this agreement will remain in effect unless I notify Pembridge directly in writing of termination.   Pembridge will notify me in writing of any changes to this consent agreement.