Payment Method Portal — Wire Transfer Form

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Wire Transfer Giro Bancario

Non U.S. Banks only Solo bancos fuera de los EE. UU.

Name of bank account owner

Address of account owner

Account number

Bank SWIFT number

Bank name

Bank address

Bank branch

Bank branch code

IBAN number

18 digit CLABE number (México only)

Intermediary bank (U.S. bank)

A.B.A./Routing number

Checking Account

Savings Account

Other

I, the undersigned, authorize MWG International, to debit from this credit card the above specified amount, related to the insurance premium. I understand that each year, in order to renew my policy, I will need to provide a new credit card authorization form. In addition, I acknowledge, that failure to provide such authorization form may result in cancellation of my policy.

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