ONLINE PAY PREMIUM

As a convenience to me, I authorize Gilsbar Specialty Insurance Services, LLC to debit my account at the financial institution I have indicated above. By clicking Submit, I understand and agree that:

• Within the next 72 hours, the amount authorized above will be drafted from my account;
• The financial institution’s rights with respect to each charge will be the same as if personally executed by me;
• This authorization shall extend to include any revised payment amounts, late charges, NSF charges, and charges which may result from revisions, under the terms thereof, to Gilsbar Specialty Insurance Services, LLC;
• This authorization shall remain in effect until I provide written notification to the contrary to Gilsbar Specialty Insurance Services, LLC that I wish to revoke such authorization, and I understand that up to thirty days' written notice may be required to act on this notice; and
• If financing, my installment payments will only be authorized by submitting the Pre-Authorized Check form by fax with a copy of my voided check.