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Bank Draft Authorization Form

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. If you need help with this form, or have any questions, please call us at 800.793.9335.

All fields are required unless marked as optional.

Member Information

First Name

Middle Initial (optional)

Last Name

Daytime Phone number (xxx-xxx-xxxx for U.S. numbers)

ID Number No dashes. Example: 123456789. If you are a new member, please enter your Social Security number. If you are an existing member, please enter your Connection Dental Plus ID number.

Bank Information

Name on Account

Bank Name

Bank Address

City

State/Province

ZIP Code Please enter your bank's five-digit ZIP code.

Bank Phone Number (xxx-xxx-xxxx for U.S. numbers)

Payment Options

Select one of the following payment options

Monthly bank draft from checking account

Quarterly bank draft from checking account

Monthly bank draft from savings account

Quarterly bank draft from savings account

Verify your correct routing number and account number with your banking institution.

Bank routing number (1)

Bank account number (2)

Disclaimer

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.

Accept disclaimer?

I decline; please cancel this authorization