433-190(05-20)

EFT AUTHORIZATION

POLICY #

NAME OF INSURED (PLEASE PRINT)

POLICY #

NAME OF INSURED (PLEASE PRINT)

Other Life policies drafting on this account: 1. Immediately draft a one-time EFT payment of $___________. The payor’s bank account will be drafted immediately

upon receipt of this form in the Home Office. 2. Set up recurring EFT payment with Draft day of (1st – 28th only)

For in force Universal Life, Variable Life or Annuity, indicate the Start Date and amount of Premium desired. Start Date: Premium: $ 3. Change Bank Account

For options 1, 2 or 3, I authorize Farm Bureau Life Insurance Company and its Affiliates (“Farm Bureau”) to electronically deduct premiums from my bank account. (Do not provide debit card numbers.)

A sample check can be found below with the important bank numbers needed:

Account Type: Checking Savings

Bank Routing Number:

Account Number:

Bank Name:

4. Change Draft day to (1st to 28th only)

5. Change EFT amount (for Universal Life, Variable Universal Life or Annuity only) New EFT amount $

Recurring electronic payments will be processed until notice to terminate this authorization is received and Farm Bureau has had reasonable opportunity to act upon it. Farm Bureau shall incur no liability should any withdrawal not be honored. This payment plan shall not be construed as a modification of any of the provisions of the policy. Scanned, faxed, photocopied and electronic signatures shall constitute original signatures. Bank Account Owner - Print Name Date Bank Account Owner - Signature Agent Number

Farm Bureau Life Insurance Company 5400 University Avenue West Des Moines, Iowa 50266-5997 PH: 1.800.247.4170 FAX: 1.800.754.6370