Withdrawal Authorization Form

ADVERTISEMENT

ACH Withdrawal Authorization
Agreement Type: ____
____
___ New Agreement
___ Change Account
(please choose one)
Employee Information [Please Print]:
Name on Bank Account _______________________________ Last 4 Soc Sec # XXX-XX-
___________
Participant Name _______________________________________________________________
Employer or Former Employer _____________________________________________________
Home Address _________________________________________________________________
Daytime Phone No. (_____)______________ Email address ____________________________
Account Information:
I authorize Crosby Benefit Systems to withdraw my portion of the monthly
premium from my:
_________ CHECKING account or
_________ SAVINGS account
Signed ________________________________________ Date __________________
Complete for Checking Account Only:
Please tape a voided check for checking account. (Do Not Staple).
Do not use a cancelled check.
Complete for Savings Account Only:
Routing/Transit Number: ___ ___ ___ ___ ___ ___ ___ ___ ___
Savings Account Number: __________________________________
Or attach a bank letter with savings routing and account number
Submission Information:
Fax completed forms to: 617-928-0001
Or mail to:
ACH Withdrawal
Crosby Benefit Systems, Inc.
P.O. Box 981401
Boston, MA 02298-1401
th
Withdrawal Timing: The payment of your premium will be withdrawn on the 10
of the month prior to the
th
month of coverage. For example, on July 10
premiums will be withdrawn for the month of August
th
coverage. If the 10
of the month falls on a weekend or holiday, funds will be withdrawn the next business
th
th
day. For example, July 10
is a Sunday so funds would be withdrawn on Monday, July 11
. If you are
mailing your ACH form after the 1st of the month, please include a check for the next month's premium.
Cancellation Information: To stop transfers, you must notify Crosby in writing at least two weeks prior to
the 10th of the month in which you wish to stop the ACH withdrawal. Please provide the date on which this
request is to be effective. Crosby will remove you from the ACH transfer system and you must begin
paying premiums by mailing a check.
:
Admin Use Only
Set Up (name) _________Date Received ___/___/___ Date Set Up ___/___/___ Paid Thru Date___/___/___
Contacted Participant:
Y
N
Amount due: $
Missing Information_______________________
TBill

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Business
Go
Page of 2