Payment Authorization for Chesapeake Life Insurance Company

Important Terms & Conditions, Please Read Carefully:

I hereby authorize The Chesapeake Life Insurance Company ("the Company") to charge the credit card or debit card account identified below (the "Account") for up to the amount specified below and to receive payment of such amount from the Account in payment of the premium with respect to the insurance policy applied for by me or by the primary applicant identified below (the "Coverage"). I understand and agree that, if any charge authorized hereby is denied, the Company will contact me to make arrangements for an alternate form of payment, and that, if I provide, verbally or in writing, corrected information for the Account or information for another credit card or debit card account (an "Alternate Account") to the Company, this Authorization includes full authority for the Company to charge the Account using such corrected information or charge any Alternate Account for the amount and purpose specified herein.
I understand and agree that

(i) the Coverage, or any portion thereof as applicable, will not be issued and will not become effective unless and until payment of the full amount of premium shall have been received by the Company;
(ii) any charge made pursuant to this Authorization will be made for payment of premium only;
(iii) reversal or contest of, or objection to, any charge made pursuant to this Authorization shall constitute failure to pay premium in full which will automatically render the Coverage, or any portion thereof as applicable, rescinded, void and unenforceable on and as of the date of issuance and will release and exonerate the Company from any and all liability under the Coverage, or any portion thereof as applicable, including without limitation liability for payment of any and all claims for benefits submitted thereunder; and
(iv) the issuer of any credit card or debit card to be charged pursuant to this Authorization is not acting and will not act as an agent of either the Company or me in accepting and paying the charge authorized hereby.

I understand the premium will be charged to the Card upon receipt of this authorization. I understand that I have the right to receive a refund of policy premium if I cancel the policy and provide written notice to The Chesapeake Life Insurance Company, at 100 Centerville Dr., Suite 100, Nashville, TN 37214, in accordance with the terms and conditions of the insurance policy.