Set up pre-authorized debit for a business account
Are you a plan administrator?
Use these forms to have group plan premiums automatically debited from your bank account. You'll find instructions on how to return the completed form on the form itself.
Download a form
Download the form and print it, or fill it out in Adobe Reader XI or higherOpens a new website in a new window - Opens in a new window (not your browser) and save.
Use this form to have your monthly premiums automatically withdrawn from your bank account.
Use this form if you’d like payments for your workplace Healthcare Spending Account and/or Medical Reimbursement Plan to be directly withdrawn from your bank account.