(Optional)

Authorization for Direct Deposits
to be retained in Employee File only

This authorizes American Independent, Inc. to send credit entries (and appropriate debit and adjustment entries), electronically or by any other commercially accepted method, to my (our) account(s) indicated below and to other accounts I (we) identify in the future (the “Account”). This authorizes the financial institution holding the Account to post all such entries.

Account #1

Account # 1 Type (e.g. Checking, Savings):___________________________________________

EMPLOYEE BANK NAME BRANCH:-___________________________________________________________________________________________________

BANK ROUTING # (ABA#) ACCOUNT #:________________________________________________________________________________________________

BANK ACCOUNT:__________________________________________________________________________________________________________________

Account #2

Account # 2 Type (e.g. Checking, Savings):___________________________________________

EMPLOYEE BANK NAME BRANCH:___________________________________________________________________________________________________

BANK ROUTING # (ABA#) ACCOUNT #:________________________________________________________________________________________________

BANK ACCOUNT:__________________________________________________________________________________________________________________

This authorization will be in effect until the Company receives a written termination notice from myself and has a reasonable opportunity to act on it, or upon my termination with the company whether it be voluntary or involuntary.

EMPLOYEE SIGNATURE:___________________________________________________________________________________________________________

EMPLOYEE PRINTED NAME:________________________________________________________________________________________________________

DATE:____________________________________________________________________________________________________________________________