I hereby authorize The University of Utah’s Income Accounting & Student Loan Services Department and the financial institution shown to initiate debit entries and, if necessary, credit the same to the financial institution and account listed below, for insurance payment. If there are insufficient funds in my bank account when it is debited, I understand I will be assessed fees similar to those charged for a dishonored check. I understand that it is my responsibility to ensure funds are available and are correctly withdrawn each month. The University will not be liable for bank charges resulting from problems associated with direct withdrawal.

This authorization is to remain in full force and effect until the University has received written notification from me (or either one of us) of its termination in such time and in such manner to afford the University and the University’s depository bank a reasonable opportunity to act on it.