Electronic Funds Transfer Form - United Healthcare - New York
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1Below is the Electronic Funds Transfer form you completed during your online enrollment.
Electronic Funds Transfer Printable Receipt
•
I am applying for an AARP Medicare Supplement Insurance Plan,
•
I have chosen to set up recurring payments for my first and future monthly premium.
I allow UnitedHealthcare Insurance Company (UnitedHealthcare Insurance Company of New York for New
York residents) hereafter named UnitedHealthcare to take a one-time withdrawal for my initial month’s
payment and set up recurring monthly withdrawals for the then-current monthly rate from the account named on
this form. I also authorize the financial institution where the account is held (BANK) to charge such a
withdrawal to my account.
This authority is active until UnitedHealthcare and the BANK receive notice from me to end withdrawals in
enough time to give UnitedHealthcare and the BANK a reasonable opportunity to act on it. I have the right to
stop payment of a withdrawal by giving notice to the BANK in such time as to give the BANK a reasonable
opportunity to act upon it. I understand such action may make my health care insurance coverage past due and
subject to cancellation.
I understand that after submitting my Online Application it will be processed in 1 to 15 business days
(pending receipt of any missing or additional required information).
Once my application is accepted, my initial payment will be withdrawn the next business day.
Thereafter, recurring monthly payments will be withdrawn on or about the fifth of each month that a premium is
due. Monthly withdrawal amounts will be for the total household payment due each month. This will include
premiums for a spouse or other member(s) of the household on the same membership account. If my coverage is
effective in the future or my account is paid in advance, EFT withdrawals will begin for the next payment due. If
my coverage is effective in the past or my account is past due, a letter will be sent that explains how to make the
payment that is due.
Billing Information
First Name: ________________________ MI ___ Last Name: ___________________________________
Address 1: _________________________________________________
Address 2: _________________________________________________
City: ______________________________ State: __________ ZIP:_______________________
Bank Routing Number: _______________________________________________
Bank Account Number: ________________________________________________________
Account Type: _________________________
Checking or Savings (statement savings only)
I have read and agree to the above.
Date:_____________________________________
BIL OLE EFT - Recurring Med Supp 3.0
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