Pre-Authorized Bank Draft - Arkansas Blue Cross And Blue Shield

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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 assure your payments are made accurately and timely.
1.
Complete the information below.
Important: Please Read Before Signing
I authorize Arkansas Blue Cross and Blue Shield, USAble Life, and the BANK indicated below, to
2.
Mail this completed authorization
debit my Arkansas Blue Cross and/or USAble Life premium from my checking or savings account
form to:
indicated below. This authority 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
Arkansas Blue Cross and Blue Shield
manner as to afford the BANK a reasonable opportunity to act on it, or until the BANK has sent me
ten (10) days’ written notice of the BANK’s termination of this agreement.
MemBRS Financial Accounts
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 and/or USAble Life coverage, UNLESS Arkansas Blue
Cross and/or USAble Life has received written notice from me of my desire to continue coverage at
Little Rock, AR 72203-3590
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)
EFFECTIVE DATE
ID NO.
USAble Life is an independent company and operates separately from Arkansas Blue Cross and Blue
Shield. USAble Life does not sell or service Arkansas Blue Cross and Blue Shield products. USAble
Life is solely responsible for the term life and critical illness policies referenced in your policy.
Form No. GF-NGF BKD (7/15)

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