This form is required for monthly or quarterly Bank Draft. Bank Draft is available from a checking or savings account. We will contact your bank to set up the automatic draft for premium payment. In the event your signature is required, we will contact you by mail at the address on file. If you need help with this form, or have any questions, please call us at 800.793.9335.
Verify your correct routing number and account number with your banking institution.
I authorize my bank listed above to pay and charge my bank account for checks drawn by and payable to the order of GEHA Connection Dental Plus on a monthly or quarterly basis as indicated above. I understand that if my signature is required I will be contacted by Connection Dental Plus and must return the signed form for automatic withdrawal to begin. I understand that I will be charged in advance of the coverage month by automatic withdrawal. This authorization shall extend to any premium increase effected by the Connection Dental Plus plan under the terms thereof. I understand that I must contact Connection Dental Plus or my bank to cancel this authorization.
If you prefer to not send this form electronically, you can print out this form and mail it to Connection Dental Plus at the address below, or send it to us by fax at 816.257.3358.