Monthly Draft Enrollment Form - Bank Draft

Pay your TMLT/TMIC invoice through automatic monthly deduction from your checking or savings account. Automatic payment remains in effect with each policy renewal period until you request cancellation. To sign up online for monthly recurring Automatic Payment, fill out the form below and click the “submit” button. A fee of $30 is assessed for non-sufficient funds.

If you have questions, contact the billing department at 800-580-8658.

Fields with an * in front of them are required.

New Authorization Change/Update Authorization Cancel Authorization
* First Name of Insured:
* Last Name of Insured:
* Email:
TMLT Account   TMIC Account   Both
* Policy #:
* Bank Name:
* Bank Account #:
* Bank Routing #:
* Bank Account Holder Name:
Checking Account   Savings Account

Legal Disclaimer
I am signing up for automatic payment of my TMLT/TMIC invoice. I agree that TMLT/TMIC may automatically charge my bank account in the amount of my monthly invoice. I can cancel automatic payment at any time by writing or submitting an electronic cancellation request to TMLT/TMIC. I agree that TMLT/TMIC or my financial institution can cancel automatic payment for my TMLT/TMIC account for any reason, at any time, with or without prior notice to me. I acknowledge that the origination of these charges to my account must comply with U.S. law. I agree that this agreement remains in effect until canceled by TMLT/TMIC, my financial institution or me.