Primary Spouse Medical Questions Additional Information Beneficiaries Agreements Summary Billing Confirmation

Billing

Credit Card Payment

This field is required.
This field is required.
Must be a future date in MM/YYYY format.
Must be exactly 3 digits.
Visa Card American Express Diners Card Discover Card Mastercard
Note: A charge from "INSURANCE 5555555555" will appear on your Credit Card Statement. Initial premium payment will be taken immediately.

I hereby authorize MWG International ("MWG") to initiate recurring payments for insurance premiums from the account provided, either by electronic funds transfer (ACH) or by charging my credit/debit card, as applicable.

I understand and agree that:

  • Each payment will be processed at the frequency and on the date selected during enrollment.
  • This authorization will remain in effect until I revoke it by providing written notice to MWG, with sufficient time for MWG to act prior to the next scheduled payment.
  • I may request a stop payment by contacting my financial institution in accordance with its procedures.

If the premium amount changes, MWG will provide advance notice as required by law prior to debiting or charging the new amount.

MWG reserves the right to terminate or suspend this payment authorization or my participation in the payment plan at any time.

If a payment is declined or returned unpaid the following will occur:

  • MWG will notify me of the failed payment.
  • The payment will not be automatically reprocessed.
  • My insurance coverage will terminate as of the last paid-through date.
  • To continue coverage, full payment of any outstanding balance must be received by MWG prior to the end of the same calendar month.

I understand that applicable non-sufficient funds (NSF) or returned payment fees may be charged, up to the maximum amount permitted by law.

Reinstatement of coverage after a failed payment is only available within 30 days of the missed payment and is not guaranteed. After two returned or declined payments, reinstatement will no longer be permitted.

You must accept the authorization to continue.

EFT/ACH – U.S. Banks only

Account Owner Address

Note: Your enrollment will be processed upon receipt of your check payment. Please allow additional time for coverage to begin.

I hereby authorize MWG International ("MWG") to initiate recurring payments for insurance premiums from the account provided, either by electronic funds transfer (ACH) or by charging my credit/debit card, as applicable.

I understand and agree that:

  • Each payment will be processed at the frequency and on the date selected during enrollment.
  • This authorization will remain in effect until I revoke it by providing written notice to MWG, with sufficient time for MWG to act prior to the next scheduled payment.
  • I may request a stop payment by contacting my financial institution in accordance with its procedures.

If the premium amount changes, MWG will provide advance notice as required by law prior to debiting or charging the new amount.

MWG reserves the right to terminate or suspend this payment authorization or my participation in the payment plan at any time.

If a payment is declined or returned unpaid the following will occur:

  • MWG will notify me of the failed payment.
  • The payment will not be automatically reprocessed.
  • My insurance coverage will terminate as of the last paid-through date.
  • To continue coverage, full payment of any outstanding balance must be received by MWG prior to the end of the same calendar month.

I understand that applicable non-sufficient funds (NSF) or returned payment fees may be charged, up to the maximum amount permitted by law.

Reinstatement of coverage after a failed payment is only available within 30 days of the missed payment and is not guaranteed. After two returned or declined payments, reinstatement will no longer be permitted.

You must accept the authorization to continue.