I hereby authorize the New Mexico Medical Insurance Pool (NMMIP) to initiate debit entries from my account and Depository designated below. Pursuant to my election, debits will be drawn on the first or fifteenth of each month unless the date falls on a holiday, then it will be drawn the next business day. Your account will be drafted for the month in which you are due (e.g., the January amount drafted is for your January coverage).

This authority is to remain in full force and effect until NMMIP and Depository have received written notification from me of this agreement’s termination in such time and in such manner as to afford NMMIP and the Depository reasonable opportunity to act upon the request.