Recurring Payment Option-Authorization Form-Unity Health Insurance

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Recurring Payment Option

DATE: ___________________

To serve you better, Unity Health Insurance offers easy recurring payment options. Schedule your

premium payment to automatically withdraw from your checking, savings or credit card account. This

will ensure your payments will always be up-to-date.

If your policy requires a binder payment to activate coverage, the recurring payment will be effective

after you have paid the binder payment, and you receive your first invoice. Complete the information

below and mail or fax to:

Unity Health Insurance

840 Carolina Street

Sauk City, WI 53583

Fax: (608) 643-2564

A monthly invoice will still be sent to you in advance showing how much will be withdrawn from or

charged to the account you have specified. If you have questions about recurring payments, please contact

our Billing Department at (800) 362-3309, ext. 1616.

________________________________________

Subscriber Name: _________________________ Subscriber Number: _______________________

Start Payment on:

due date

___ days before due date

Email: _______________________

Checking

Savings Account

Credit Card

Visa

MasterCard

Checking

Savings

Name on Acct:

____________________

Discover

Bank Name:

____________________

Cardholder Name: _________________________

Account Number: ____________________

Account Number: _________________________

Bank Routing #: ____________________

Exp. Date:

_________________________

Bank City

State: ____________________

NOTE: enclose a voided check or letter from your bank when paying from a checking or savings account.

SIGNATURE:

DATE:

I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Unity Health Insurance in writing of any changes

in my account information or termination of this authorization at least 15 days prior to the next billing date. If the above noted payment dates fall on a

weekend or holiday, I understand that the payments may be executed on the next business day. For ACH debits to my checking/savings account, I

understand that because these are electronic transactions, these funds may be withdrawn from my account as soon as the above noted periodic

transaction dates. I certify that I am an authorized user of this credit card/bank account and will not dispute these scheduled transactions with my bank

or credit card company as long as the transactions correspond to the terms indicated in this authorization form.

UH01607 (0516)