Electronic Funds Transfer (Eft) Authorization Form
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2Electronic Funds Transfer (EFT)
Authorization Form
Save time and money with Automatic Deduction from your bank account.
You can have your monthly premium payments automatically deducted from your bank account using
our Electronic Funds Transfer (EFT) process.
EFT is safe and convenient, plus it saves you money on postage. Your monthly premium payment will
be automatically deducted on or around the
day of every month.
EFT is one of the easiest ways to pay your premium
.
•
You don’t have to write out a check and mail it each month.
•
You won’t have to remember to mail your premium if you travel or become ill.
•
Your check will never be delayed or lost in the mail.
Signing Up For EFT Is Easy!
It takes just a few minutes to set up your monthly premium payment for automatic deductions from
your bank account. All you have to do is:
1.
Complete the Electronic Funds Transfer (EFT) Authorization Form below.
2.
Write “VOID” on a blank check from the account you would like the EFT payments withdrawn from.
Do NOT send a deposit slip.
3.
Return the completed Electronic Funds Transfer (EFT) Authorization Form and blank voided check
to UnitedHealthcare, P.O. Box 29350, Hot Springs, AR 71903-9350. Once your completed form is
by mail of the date your EFT begins.
You should continue to pay your monthly premium using your current payment method until that time.
Detach & mail with blank voided check
Electronic Funds Transfer (EFT) Authorization Form
I authorize UnitedHealthCare Insurance Company (UnitedHealthCare Insurance Company of New York for New York
residents), or
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account named on this form and authorize the named banking facility (BANK) to charge such withdrawals to my
account.
Bank Account Holder Name: _______________________________________________________________________
Bank Name: ____________________________________________________________________________________
Bank Routing #: ___/___/___/___/___/___/___/___/___/
Bank Account #: ________________________________
Bank Account Holder Signature: ________________________________________ Date: _______/_______/_______
The reverse side of this form must also be completed. >
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Parent category: Medical