Common Contracts

Automatic Bank Draft Authorization Agreement

June 10th, 2019

• Filed
  June 10th, 2019

Please provide the following information. Deduct premium from the following:🞏 Checking Account (Attach a blank, voided check.)🞏 Savings Account (Verify the correct routing number with your bank/financial institution.) Routing #:- Deduct premium on the following basis. (Funds will be transferred on the premium due date.) 🞏 Automatic Monthly Premium Payment Requested Start Month Name of bank/financial institution Account number City State ZIP code Member name (please print) Anthem 9-Digit Identification Number (as displayed on ID card) Date of Birth (DOB) Account holder's name Account holder's signature Date