Hospital Name:*
 
 
Hospital Phone Number:*
 
 
Email Address:*
 
 
Country:*
 
 
City:*
 
 
State:*
 
 
Province:*
 
 
Hospital Bank Name:*
 
 
Name on Account:*
 
 
Checking/Savings:*
 
Checking
Savings
 
Hospital Routing Number:*
 
 
Hospital Account Number:*
 
 
Would you like to receive automated EFT reports?*
 
 
How often would you like to receive your automated EFT reports?*
 
 
Which email address(es) should receive the automated EFT reports?*
 
 
Additional Notes (Optional):
 
 
Bank Code:*
 
 
Name of Person Submitting this Form:*
 
 
Terms & Conditions
I (we) authorize Trupanion Managers USA, Inc., and/or its affiliates, hereinafter COMPANY, to make deposits, and appropriate debit adjustment entries, into my (our) account with the Financial Institution indicated above. This authority is to remain in effect until COMPANY has received written notification from me (or either of us) of its termination such that COMPANY and the Financial Institution have a reasonable opportunity to act on it. 
Terms & Conditions
I/we authorize Trupanion Managers USA, Inc. (”Trupanion”) to credit and/or make debit adjustments to my account and financial institution indicated above. This Pre-authorized debit/deposit plan may be terminated by either Trupanion or by me/us through written notice. This authority is continuing and to remain in effect until Trupanion has received written notification from me/us (or either of us) of its termination such that Trupanion and the financial institution have a reasonable opportunity to act on it. Deposits will be made within two to five working days following the approval of your deposit. Your deposit will be confirmed by email.

You have certain recourse rights if any debit does not comply with this agreement. For example, you have the right to receive reimbursement for any debit that is not authorized or consistent with this Plan Agreement. To obtain more information on your recourse rights, contact your financial institution or visit www.cdnpay.ca. I/We waive any and all requirements for pre-notification of debiting, including, without limitation, pre-notification of any changes in the amount of the PAD due to a change in any applicable tax rate, top-up or adjustment.

I authorize Trupanion to collect, use, maintain and disclose my personal information with the following persons, organizations or parties: companies affiliated with Trupanion; financial institutions; government agencies; and/or service providers for the purposes of operating the Plan. I agree that a photocopy or electronic copy of this form is as valid as the original. I certify that the information given is true, correct and complete to the best of my knowledge.

I/We warrant and guarantee that the person(s) whose signature(s) are required to sign on the account indicated above have signed this agreement.  
Agree to Terms & Conditions:*