Withdrawal Authorization Form (Page 2 of 2) in pdf

ACH Withdrawal Questions and Answers

Q. How do I set up an ACH withdrawal for my portion of the monthly premium?

A. Complete the ACH Withdrawal Authorization Form. To withdraw from a checking account, attach a

voided check to the form. To withdraw from a savings account, provide the requested information (it is

recommended that you obtain a letter from your bank identifying the account and transit/routing

number for your bank). Mail to the address indicated on your Employer or Former Employer's

ACH Withdrawal Authorization Form.

Q. Can I attach a cancelled check instead of a voided check?

A. No. You must attach a voided check not a cancelled check. If you attach a cancelled check, you

may be at risk of the bank negotiating your check again.

Q. Can I fax the authorization form to Crosby?

A. Yes, you may fax the form and copy of your voided check to Crosby at 617-928-0001.

Q. What happens if I do not complete the authorization form correctly or do not include the proper

documentation?

A. We will contact you if your form is not completed correctly or if additional documentation is required.

You will continue to pay your premium with a “live” check until the ACH has been set up.

Q. Can I make my initial payment by ACH?

A. No. You must make your initial payment by check or money order.

Q. How do I know when my ACH payment will begin?

A. In order for the ACH process to take effect, your premiums must be paid through the month prior to the

start date of the ACH request. If your ACH form is received at Crosby on or before the 1st of the

month and your premiums are paid through the next month, your ACH will take effect for the next

month's premium. For example, if your ACH form is received on January 1st, your premium must be

paid through February in order for the ACH transaction to be initiated for February premiums.

Q. When will the premium be withdrawn from my account?

A. The payment of your premium will be withdrawn on the 10

of the month prior to the month of

coverage. For example, on July 10

premiums will be withdrawn for the month of August coverage. If

the 10

of the month falls on a weekend or holiday, funds will be withdrawn the next business day.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is a Sunday so funds would be withdrawn on Monday, July 11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.

Q. How do I stop ACH transfers? What if I close or change my account?

A. To stop transfers, 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. If you would like to request premium payment coupons, contact us 800-462-2235.

Withdrawal Authorization Form Page 2