Common Contracts
1 similar Authorization Agreement for Automatic Payments contracts
Authorization Agreement for Automatic PaymentsAuthorization Agreement for Automatic Payments • January 20th, 2015
As a convenience to me, I hereby authorize Delta Dental of Washington to initiate entries to my bank account for monthly dental premiums. I understand this will occur each month and that a record of the transaction will appear on my monthly bank statement. I agree that each payment shall be the same as if it were an instrument personally signed by me. This authorization will remain in effect until revoked by me in writing to Delta Dental of Washington. In addition, I have the right to stop payment of a charge by timely notification to my financial institution prior to my account being charged. I understand, however, that both my financial institution and Delta Dental of Washington reserve the right to terminate this payment plan (or my participation therein). By signing below, I agree to the follow terms:
