Authorization Agreement Form - Blue Cross And Blue Shield Of Illinois printable pdf download

Automatic Premium Payment

Authorization Agreement

Take these simple steps for hassle-free monthly premium payments:

• Verify with your financial institution that it can accept automated electronic withdrawals.

• Complete this request online by going to and logging on to Blue Access for Members.

• If submitting by fax, please fax this form to 1-800-625-5916.

• If submitting this form by mail, please use this address:

Blue Cross and Blue Shield of Illinois

P.O. Box 3236

Naperville, IL 60566-9708

If you have any questions about this program, please call our Member Service Department toll-free at 1-800-538-8833.

AGREEMENT

I request and authorize Blue Cross and Blue Shield of Illinois (BCBSIL) and/or its designee to obtain payment of amounts becoming

due by initiating charges to my account in the form of checks, share drafts, or electronic debit entries, and I request and authorize

the Financial Institution named below to accept and honor the same to my account. As the account holder, by signing below, I also

certify, in the event that this draft is being drawn from a company checking account, that I am authorized to approve this transaction,

that the company is not paying any portion of the premium for this subscriber, either directly, or through reimbursement, and that

the employer/company is not deducting any part of the premium from gross income under section 106 or section 162 of the Internal

Revenue Code. I understand that both the financial institution and BCBSIL reserve the right to terminate this payment program and/

or my participation therein. I also understand that I may discontinue this payment program at any time with at least 10 days advance

notice to Blue Cross and Blue Shield of Illinois by telephone prior to a scheduled withdrawal date.

Please complete the following

Yes

No Deduct ongoing monthly premium payments only from my checking or savings account. Drafts will be drawn

on the premium due date. If the draft date falls on a non-business day or a holiday, the premium payment will

be deducted from my account on the next business day. Please ensure adequate funds are available at the time

of application. Blue Cross and Blue Shield of Illinois is not responsible for fees incurred due to insufficient

funds. Select one of the following draft options.

1 MONTH BANK DRAFT PREMIUM AMOUNT EACH TIME

(12 PAYMENTS PER YEAR)

Yes

No SelecTEMP PPO

only – Upon receipt and approval of my SelecTEMP PPO application, please deduct the

premiums due for the length of coverage designated.

___________________________________________

BCBS member ID/applicant’s Social Security number:

_____________________________________________________________

Name of member/applicant:

________________________________________

Name of depositor(s) if other than the member/applicant:

________________________________________________

Phone number of member/applicant/depositor:

Name of bank, city and state

_____________________________________________________________

where account is authorized:

_____________________________________________________________

Please check one:

q Checking Account q Savings Account

Your Name

1000

____________________________

Bank Transit Number:

Your Address

Your City, State & Zip

DATE

_______________________

Depositor’s Account Number:

PAY TO THE

ORDER OF

DOLLARS

I have read and accept the above agreement.

MEMO

Bank check –

Please continue to pay your premiums by check or money

999999999

99999999999

1000

bottom left corner

order until you receive a confirmation letter from us stating

{

Bank Transit Number

Depositor’s Account

the date automatic payments will begin.

________________________________________

________________________

Depositor’s Signature:

Date:

A Division of Health Care Service Corporation, a Mutual Legal Reserve Company, an Independent Licensee of the Blue Cross and Blue Shield Association

31561.0914

Authorization Agreement Form - Blue Cross And Blue Shield Of Illinois

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