Form Mltrc1001ge - Group Tricare Standard/extra Supplement Plan Enrollment Form Page 3
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3Automatic Payment Option (APO)
Savings or Checking Account Deduction Authorization Form
1. Applicant’s Information (proposed insured)
Applicant’s Name ____________________________________________________ Date of Birth ____/____/____
Street Address ________________________________________________________________________________
City___________________________________________________ State______ Zip Code __________________
Please list the Insurance Policy you wish to have premium deductions made from the account indicated below:
Policy Number:
_________________________________ Type of Insurance: ___________________________
2. Financial Institution Information
Depositor Name (Payor) _________________________________________________________________________
(As it appears on Financial Institution Records)
Financial Institution Name _______________________________ Account Number _________________________
(Include Branch Name)
Financial Institution City____________________________________ State______ Zip Code _________________
3. Account Selection: I authorize an automatic deduction from my (please choose one):
Checking Account. Attach a sample VOIDED check.
Savings Account. Account Number: ______________________ Routing Number: _____________________
Premium deduction should be made:
Monthly
Quarterly
Semi-Annually
Annually
Please include your first modal premium check made payable to Selman & Company. All subsequent premium
payments will be made as indicated above.
4. Signature/Authorization
In accordance with the agreements and conditions listed below, I hereby request and authorize Selman & Company to
initiate debit entries on the Financial Institution account listed herein for the purpose of paying premium. This
authorization is to remain in full force and effect until Company and Depository have received written notification from
me of its termination in such time and manner as to afford Company and Depository a reasonable opportunity to act on
such notification. Written notification must be mailed to: Selman & Company, 6110 Parkland Boulevard ,Cleveland, OH
44124-4187.
Signature of Depositor _________________________________________________________________________
Print Name of Depositor ______________________________________________________ Date ____/____/____
Signature of Applicant/Insured
(If different from Depositor) ____________________________________________________________
Print Name of Insured/Applicant _______________________________________________ Date ____/____/____
5. Agreements & Conditions
Automatic Payment Option (Account Deduction Authorization) is subject to the following conditions:
1. Premium payments will be debited from your account on or about the premium due date.
2. Additional premium that may be required in order to keep policy(ies)/certificate(s) current may be drawn from your
account through the use of multiple debits.
3. Selman & Company (Company) may revoke the privilege of paying premium under this Automatic Payment Option
(APO) if any payment is dishonored.
4. A service fee of $15.00 may be assessed for each dishonored payment.
5. Payment of premium under APO may be discontinued by the Company or the undersigned upon thirty (30) days
written notice.
6. If APO is discontinued, an alternate payment mode acceptable to the Company will be used to remit the premiums
needed to keep the policy(ies)/certificate(s) in force and current.
7. The Company will not send premium notices while APO is in effect.
8. A request for change or adjustment to the APO must be sent directly to the Company’s Customer Service
Department.
9. If you cancel this service, any refund of premium due you will take sixty (60) days to process.
NOTE: Please keep a copy of this completed document for your record.
0115 APO
OFFICE USE ONLY
Insured ID: ________________________________
APO Effective Date: _______________
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