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Pre-Authorized Bank Draft

Monthly Program Sign-up Form

Our monthly bank draft service makes premium payments easy and convenient for you. Just a few

steps now help ensure your payments are made accurately and timely.

Complete the information below.

Important: Please Read Before Signing

Mail this completed authorization form

I authorize Arkansas Blue Cross and Blue Shield and the BANK indicated below, to debit my

Arkansas Blue Cross premium from my checking or savings account indicated below. This authority

and the voided check to:

is to remain in full force and effect until my BANK has received written notification from me of the

Pre-Authorized Bank Draft Program termination in such time and manner as to afford the BANK a

Arkansas Blue Cross and Blue Shield

reasonable opportunity to act on it, or until the BANK has sent me ten (10) days’ written notice of

Attn: Cashiers (Drafts)

the BANK’s termination of this agreement.

I understand that by revoking the Pre-Authorized Bank Draft Program after I have agreed to it, I also

P.O. Box 3590

will be terminating my Arkansas Blue Cross coverage, UNLESS Arkansas Blue Cross has received

Little Rock, AR 72203

written notice from me of my desire to continue coverage at least twenty (20) days prior to the next

Pre-Authorized Bank Draft Program withdrawal date.

I understand that an insufficient check fee will be assessed for any payment returned to Arkansas

Blue Cross as a result of insufficient funds.

INSURED(S) INFORMATION

First Name_____________________________________

Last Name ________________________________________

Address _________________________________________________________________________________________

Street

Apt. No

_________________________________________________________________________________________

City

State

Zip

Arkansas Blue Cross and Blue Shield Member ID __________________________________________

Please check one of the following:

Currently, the insured’s premium is not drafted

Currently, the insured’s premium is drafted

and the account information has changed

BANK ACCOUNT INFORMATION

Bank Name: _______________________________________ Name on Account: ________________________________

(If different than the insured)

Routing Number: ___________________________________ Account Number: _________________________________

Type of Account: o Checking o Savings

SIGNATURE

Signature______________________________ __________________________ _

Date____________________________

Signature of Bank Account Holder

After Arkansas Blue Cross receives and processes this completed authorization form, you will receive a letter providing the

effective date of your first scheduled draft. We hope you find this bank draft service of value. It is our privilege to serve you.

Thank you for your business!

For Office Use Only (Please do not write in this space)

ID NO.

EFFECTIVE DATE

Form No. OE Dental CF (R12/15)

Individual And Family Dental Change Form (Start Date Of January 1, 2014 Or Later) - Arkansas Blue Cross And Blue Shield Page 4

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