card change doc

1. 1003894 2001 141641 201135329 Printed in U.S.A. 07-27-2011
1156-7763-13A Request for State Farm Payment Plan's
Recurring Monthly Payment Option:
I hereby authorize State Farm®
affiliates and subsidiaries (State Farm) and the financial institute designated (or any other financial
institution I may authorize at any time) to deduct/charge monthly regular recurring payments required for the payment of insurance or
loan repayments from my chosen method below from either my financial account or credit/debit card.
This authority remains in effect until State Farm has received written or electronic notification from me of its termination at least ten (10)
business days before the next scheduled payment at the appropriate address provided below.
Financial Institution name: N/A
Financial Institution routing/transit number: N/A
Financial Institution account number: N/A
Account type: FINANCIAL CARD
Last 4 characters on card number: XXXX XXXX XXXX 5303
Expiration: 08/2018
It is my responsibility to provide and maintain the most up to date and accurate financial information shown above.
If any transaction is not honored by my financial institution, the policies or loans will be considered not paid. State Farm will ask me to
pay the dishonored transaction amount with a replacement payment and will suspend the recurring payment option. After timely
replacement payment is received by State Farm, recurring payment option will resume. State Farm has the right to charge me for any
payment dishonored by my financial institution or any payment that is received after the due date.
State Farm has the right to discontinue the recurring payment option for any reason. State Farm will send notification to me at least ten
(10) days in advance whenever the payment amount or the requested payment date changes.
I understand and agree State Farm has no obligation to and will not apply any loan repayment amount toward any payment which is
unpaid.
State Farm may revise the terms of this agreement at any time upon written notification. I acknowledge that I have received and agree
to the terms of the State Farm Payment Plan Agreement.
Note – the date of the actual deduction/charge may vary based on the processing times of the financial institutions.
Print name of State Farm Payment Plan Accountholder
Print name of Payor Signature of Payor Date
02/12/2014
Contact Information:
KLAUDIA CHILCOAT
301 S 32ND ST
CAMP HILL, PA 17011-5129
(717)761-3589
KLAUDIA.CHILCOAT.J8OD@STATEFARM.COM
State Farm Affiliate Insurers:
The type of payment plan and the state in which the insured lives will determine which of the State Farm affiliates will initiate the authorized recurring
deduction/charge. An insured may have an agreement with more than one State Farm affiliate for different premium payment plans and different
payment options.
The State Farm affiliate insurers are:
State Farm Mutual Automobile Insurance Company State Farm Fire and Casualty Company
State Farm International Life Insurance Company, LTD State Farm General Insurance Company
State Farm Life and Accident Assurance Company State Farm Florida Insurance Company
State Farm Life Insurance Company State Farm Lloyds
State Farm Guaranty Insurance Company State Farm Indemnity Company
State Farm County Mutual Insurance Company of Texas

2. 1004029 2000 141839 200
State Farm® Payment Plan Agreement
1. By payment of the initial premium and set up fee to establish this State Farm Payment Plan (SFPP) account, you
agree to the terms of this SFPP account, as set forth below. If at any time you do not agree to any of these terms,
notify your State Farm agent who will help you determine the payment method available and you will be billed
directly using that payment method for each insurance policy. Subject to the provisions below, this agreement is
intended to continue for as long as you are a State Farm insured.
2. This SFPP agreement is between you and the State Farm Mutual Automobile Insurance Company, its subsidiaries
or affiliate insurers (State Farm) for the payment of premium on the insurance policies issued to you by the various
affiliated State Farm insurance companies. This SFPP agreement is NOT an insurance application. This SFPP
agreement alters only your obligation to pay premium in advance for the full term of the various State Farm policies.
Except for item 8 below, the other terms of those insurance policies are not altered by this SFPP agreement.
3. State Farm agrees to accept periodic premium payments (monthly, quarterly, semiannually) rather than the full
premium for the entire term of your insurance policies. In order to continue coverage, you must pay the full amount
of the periodic premium payment and premium installment charges. The premium installment charge applies as
listed below:
• Non Recurring Accounts $3.00
• Recurring Accounts Print Billing Notice $2.00 (Requested a billing be mailed each month)
• Recurring Accounts $1.00
Automated Recurring Accounts are only available for eligible monthly billing modes. If you change the type of
periodic premium payments on the SFPP, it does not alter terms of this agreement.
4. You may pay premium for more than one State Farm policy through your SFPP account. In that case, each periodic
payment through your SFPP account is the premium installment charge and the total of the periodic premium
payment due for each of the State Farm policies paid for through your SFPP account. We will not credit the periodic
payment received to any one specific policy unless you clearly indicate otherwise with, or prior to making, the
periodic payment.
5. If at any time within a single year you receive three (3) cancellation notices for failure to pay, you may be ineligible
to continue your SFPP account. The discontinuation of an SFPP account does not relieve you of the obligation to
pay premiums due on your State Farm insurance policies.
6. You may close your SFPP account at any time by merely providing notice to State Farm or your State Farm agent.
Closing your SFPP account does not relieve you of the obligation to pay premiums due on your State Farm
insurance policies. Separate billings may be sent to you for each insurance policy.
7. You or State Farm may cancel a State Farm policy in accordance with the terms and conditions of that State Farm
policy. If you wish to cancel any or all policies on your SFPP account, you must comply with the procedures
outlined in each of those policies.
8. If any of your State Farm policies paid through this account result in paid unearned premium, State Farm may:
a. Credit any money due to you against the premium owed by you on any other State Farm insurance
policy paid for by you through your SFPP account; or
b. Refund the money to you.
9. State Farm has the right to close your SFPP account at anytime.
10. The set up fee, premium installment charge and earned periodic premium payment paid by you are not refundable.
11. If you signed and completed the Request for State Farm Payment Plan's Recurring Monthly Payment Option,
authorizing the deduction of your premium payments from your financial account, you also agree to the terms of
this SFPP Agreement as set forth above.
12. This SFPP agreement does not in any way affect the terms of the Request for State Farm Payment Plan's
Recurring Monthly Payment Option.
13. State Farm may revise this SFPP agreement at any time upon written notification.
STATE FARM INSURANCE COMPANIES 135323 Printed in U.S.A. 02-27-2011