By pressing Secure Send, you are sending this information in 256-bit encryption to Merit as authorizing the payment charge(s) as set out on your Insurance Premium Financing Agreement. You are effectively placing your signature authorizing this by pressing Secure Send. This does not automatically submit payment for withdrawal or charging, it transmits the information securely to Merit for it to process on behalf of the customer. The payment mechanism use is hereby fully authorized by agency as if the card holder requested immediate withdrawal of funds. Payment for insurance is not refundable except as may be returned by the insurer. You are authorizing Merit to adjust payment amount based on additional or credits as may be applied on your account or otherwise to adjust amounts for renewal premiums as set out on the premium financing agreement. Further, you are irrevocably authorizing the application of the convenience fee for system access to process these charges in addition to any fees charged for your insurance and premium financing.  This convenience fee is required to cover third party costs of payment processing and is standard on items priced as dollars such as mortgage, taxes, tuition, and insurance. The convenience fee is subject to change from time to time commensurate with costs of processing changes.  You may be responsible for additional charges related to payment processing. The insurance is fully delivered on its inception date. Charges will appear as Merit Finance and are inclusive of both insurance premium installments and the convenience fee. Monies received to Merit will apply first to the Convenience Fee then to Merit Premium costs due.  In the event that these charges are not paid, you authorize further charges to cover any further collection costs or fees incurred by Merit or to pay for NSF or late fees. You can use other payment mechanisms at Merit to avoid convenience fees.  A receipt by email will be automatically generated for any charges applied. The signature authorizing payment on file shall apply to irrevocably authorize these payments, or your agency documentation shall authorize payments, and pressing submit here is an agency or direct electronic authorization by the holder of the account information provided for so long as the agreement shall apply.  Pressing submit provides full authority to proceed for all amounts due. 

CONSENT AND DISCLOSURE

MY / OUR SIGNATURE/ OR ASSENT IN COMPLETION WITH OR WITHOUT SIGNATURE EXPRESSLY OR IMPLIEDLY CONFIRMS THAT:

1) I/We have been provided with details of and understand the terms and conditions of the payment plan by automatic withdrawals from my/our financial institution account and/or credit card.

2) I/We hereby authorize the named financial institution to debit my/our account for all payments payable to: Merit Insurance Premium Financing ("Merit") in payment of the insurance premiums and any applicable charges and taxes.

3) I/We understand that this authorization may be cancelled by me/us upon written notice, subject to a period which shall not exceed 30 days. I/We may obtain a sample cancellation form, or further information on my/our right to cancel a payment authorization agreement, at my/our financial institution or by visiting www.cdnpay.ca.

4) I/We have certain recourse rights if any debit does not comply with this agreement. For example, I/we have the right to receive reimbursement for any debit that is not authorized or is not consistent with this payment authorization agreement. To obtain more information on my/our recourse rights, I/we may contact my/our financial institution or visit www.cdnpay.ca.

5) I/We warrant and guarantee that all persons whose signatures are required to sign on this account have signed this authorization.

6) I/We agree that, if there is a change in premium due to a change in coverage, rate, or upon renewal, the amount of the monthly withdrawal will automatically be changed.

7) I/We will ensure that funds are available on each due date and understand that Dishonoured Funds transactions may result in one or all of the following:

1. A second presentation or attempt to withdraw funds

2. A second withdrawal notice

3. Cancellation of the policy

8) I/We acknowledge that the rights and obligations provided in accordance with the Canadian Payments Association Rule H1 concerns only pre-authorized debits, not recurring charges to credit cards.

9) I/We agree that, for pre-authorized debits, only the insured shall receive written notice from Merit of the amount to be debited and the due date, at least 10 calendar days prior to the date of the first payment, and any change in the amount or date of the payment unless requested to be changed by the broker or insured and therefore waived.

10) I/We waive the right to obtain written notice from Merit Insurance Premium Financing, of the amount to be debited and the due date(s) of debiting, at least 10 calendar days prior to the date of the payment, even when there is a change in the amount or payment date(s).

11) I/We undertake to inform Merit Insurance Premium Financing, in writing, of any change in the account information provided in this authorization 10 calendar days prior to the next payment due date.

12) The account that my/our financial institution is authorized to draw upon is indicated above. A specimen cheque marked “void” or bank issued account information form is attached to this authorization or otherwise account information is provided as equivalent thereto (PAP authorization or instruction or account information with implied direction).

13) I/We acknowledge that Merit is not required to verify that the pre-authorized debit was issued in accordance with the particulars of the Payor's Authorization including, but not limited to, the amount as may be due at any time.

14) I/We understand that this authorization is continuous and will automatically apply to the renewal terms, unless instructed differently.

15) I/We authorize Merit to collect or use my/our personal information for the purpose of this authorization for automatic withdrawals for payment of the insurance premiums and any related costs or fees including convenience fees that cover costs of system access.

I/We authorize Merit to disclose any personal information contained in this authorization form to its financial institution to the extent disclosure is directly related to and necessary for the proper execution of the pre-authorized debit transaction for the policy number noted above.

16) I/We may obtain a copy of or ask questions about the broker's or Merit's personal information policies by contacting their respective privacy officers.

17) I/We may withdraw my/our consent to collect, use or disclose my/our personal information for the purpose of this authorization for automatic withdrawals for payment of the insurance premiums. Withdrawal of my/our consent will result in cancellation of this authorization for automatic withdrawals for payment of the insurance premiums, in which case the insured must make other arrangements for payment of the insurance premiums. Withdrawal or cancellation is only valid if in writing and delivered to Merit and any related costs shall remain owing and fees may be incurred. Please note that a transaction fee may apply to any "Dishonoured Funds" or “Late” charges or any other fees or costs imposed including by any third party for “convenience fees”.

18) I/We have received a copy of this authorization and have read and understand these terms and conditions.  By engaging in any payment, or by making any payment, it is implied and expressed consent to these terms.  I/We have engaged our insurance broker as our agent to make any directions, representations or otherwise with respect to insurance and paying insurance premiums and costs and therefore Merit may rely upon their direction as if it is the direction of the card holder based on providing that information to the broker or to Merit.