Common Contracts
1 similar Authorization Agreement for Automatic Payments contracts
Authorization Agreement for Automatic PaymentsAuthorization Agreement for Automatic Payments • October 26th, 2020
Subscriber name: Subscriber address: City: State: Zip code: Applicant telephone number: Authorization for automatic paymentsI hereby authorize Blue Care Network, hereinafter called BCN, to withdraw from my checking/savings account amounts necessary to pay the premium owed by me under my BCN contract. This authority will remain in effect until I notify you, or the bank listed below, in writing to cancel it in such time as to afford the bank a reasonable opportunity to act on the cancellation. Bank name: Branch: City: State: Zip code: Please deduct my monthly BCN premium from (check one):Checking account (Please include a voided check when you return this form.) Savings account (Please include a voided deposit slip when you return this form.)If you bank online, please write in your checking or savings account number and bank routing number.Account number Bank routing number Signature: Date:
