Direct Credit Authorisation Form

We are only processing direct credit transactions for certain New Zealand policies at this time.

Please select a valid Country.
Please select a valid Type of Transaction.
Please select a valid Claim Type.

Personal Information

Please enter a valid Policyholder Name.
Please enter a valid Policy Number.
Please enter a valid Address.
Please enter a valid City.
Please select a valid State/Province.
Please enter a valid Zip/Postal code.

Bank Information

Please enter a valid Name of Account.
Please enter a valid Bank Name.
Please select a valid Account Type.
Please enter a valid Routing Number.
Please enter a valid Bank Transit Number.
Please enter a valid Branch Location.
Please enter a valid Account Number.
Account Number must match.
  • A PDF copy of a voided check
    •
  • PDF copy of a printed account verification screen signed and stamped with the bank stamp
  • A PDF bank statement
  • A PDF copy of screen shot from a Mobile Bank device
Only PDF files are currently supported.

By clicking “submit” I authorize American Income Life Insurance Company to deposit payments to my financial institution electronically. I understand that American Income Life Insurance Company will reverse any payments made to my account in error.

By clicking submit, I authorize American Income Life Insurance Company to deposit funds directly in to my specified account. If the company erroneously deposits funds in to my account, I authorize the company to initiate the necessary debit entries not to exceed the total of the original amount credited to my account. I understand that this authorization will remain in full force and effect until I notify the company in writing that I wish to revoke this authorization in such a time and manner as to afford the company a reasonable opportunity to act on such request.

Your submission has been received and will be processed shortly.

There was an error with your submission, please try again or contact us if problems persist.