Name & Address of Insured/Borrower: KENTUCKY STATE UNIVERSITY

400 E. MAIN STREET FRANKFORT, KY 40601

Telephone Number: (502)597-5827

Name & Address of Account Holder (If different from above):

Telephone Number: ( ) - Email Address:

IPFS Use Only: Quote No.: ILC-20203109 Debit Begins: 08/01/2022

IPFS

125 S. WACKER DRIVE SUITE 1650 CHICAGO, IL 60606 Phone: (877)242-0069 FAX: (877)242-0685 ILC.Processing@ipfs.com

Please verify with your bank that the bank routing number for ACH transactions is the same as listed on your check or deposit slip.

Bank Account Title(Name): ___ [ ] Checking or [ ] Savings

Financial Institution: ___ ABA #/Routing #: ___

Address (City, State, ZIP): ___ Acct No: ___

Number of Payments: 10 Payment Amount: 41,025.91 First Payment Due: 08/01/2022

I hereby authorize IPFS Corporation (IPFS) to initiate electronic debit entries to the account indicated on this form, from the financial institution identified above (BANK). I authorize BANK to honor the debit entries initiated by IPFS and debit the same to such account. This authority pertains to all financial obligations existing from time to time under the Premium Finance Agreement (PFA) I enter into with IPFS, including but not limited to scheduled payments and the cash down payment described in the PFA (or) revised payment amounts resulting from revisions to the PFA or otherwise, and applicable fees and charges.

The debits for scheduled payments will be in accordance with the schedule of payments disclosed in the PFA, with a debit occurring on the First Payment Due Date, and on the subsequent same day of each month (or per the PFA Schedule of payments if different) thereafter, until all scheduled payments have been made. If the payment due date falls on a weekend of holiday, IPFS will debit the account on the following business day. I understand that funds must be available in the account on the date the debit is made.

I understand and agree that each time the BANK rejects a debit entry for Non-Sufficient Funds (NSF) or Account Closed, my account with IPFS will be assessed the maximum NSF fee permitted by law not to exceed $40.00. The NSF Fee may be electronically debited from my BANK account indicated on this form. I also understand and agree that IPFS may re-initiate a debit returned NSF up to two more times, and the re-initiated debit may occur on a date other than my regular payment due date.

I also understand and agree that this authorization is to remain in force until (1) IPFS receives from me a signed written notice of revocation, sent to the IPFS address set forth above by first class mail postage prepaid in such time and manner as to afford IPFS a reasonable opportunity to act on it; OR (2) I have received written notification from IPFS that this authorization and agreement is terminated for rejection of a debit entry due to NSF or Account Closed.

By: ___ Date ___

(Account Holder or Authorized Signatory of Account Holder)

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