I/​We authorize and instruct Doctors Manitoba and my/​our designated financial institution (or any other financial institution I/​we may authorize at any time) to deduct regular recurring payments for all charges arising from my/​our Doctors Manitoba insurance(s) as indicated above. Monthly payments will be debited from my/​our specified account on the 10th or 20th day of each month. Annual payments will be debited to my/​our specified account on the first business day of January or June/​July. I/​We understand that the amount of the deduction may change at a future date and, if so, that pre-authorized debits will continue and reflect such changes. Doctors Manitoba will advise me/​us in writing of the revised amount at least ten (10) days before the debit date.

I/​We acknowledge and agree that Doctors Manitoba may charge me/​us an administration fee of up to $10 per occurrence for any dishonoured pre-authorized debit (including, but not limited to, non-sufficient funds, stop payments and closed accounts).

Doctors Manitoba may not assign this authorization, whether directly or indirectly, by operation of law, change of control or otherwise, without providing at least ten (10) days prior written notice to me/​us.

I/​We understand that this authority will remain in effect until I deliver to Doctors Manitoba a written notification from me/​us changing or terminating it. I/​We understand that I/​we must provide at least ten (10) business days notice to Doctors Manitoba before the next debit is scheduled. I/​We may obtain a sample cancellation form, or more information on my/​our right to cancel, at my/​our financial institution. I/​We understand that I/​we have certain recourse rights if any debit does not comply with this authorization. For example, I/​we have the right to receive reimbursement for any debit that is not authorized or is not consistent with this authorization. I/​We understand that I/​we may obtain a form for a Reimbursement Claim, or more information on recourse rights, from my/​our financial institution or at www​.cdnpay​.ca.