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Payment Methods for Individual Dental Applications California

Applicant / Member Name:

Primary Applicant s SSN:

(Premium Payment is required. Please choose from Option 1 or 2.)

OPTION 1 – If you choose the following option for INITIAL and FUTURE MONTHLY payments, you are NOT required to make a selection from Option 2 for your initial payment.

Monthly Checking Account Automatic Premium Payment (complete Section A)

OPTION 2 – If you did not select OPTION 1, please choose from the options below for your INITIAL premium payment. If you choose one of these options, you will receive a bill every month thereafter.

Paper Check*

Electronic Check (complete Section B)

Credit / Debit Card (complete Section C)

A. Monthly Checking Account Automatic Premium Payment – By providing your check information, you authorize us to debit your bank account electronically. If you have selected this option, your bank account will be debited one month’s premium as soon as the day of approval. Subsequent premium amounts will be debited on the day

you request below: Requested Debit Day: (1st to 6th of each month). If no date is specified, your _____ premiums will be debited on the 1st of each month.

Provide your Routing and Account Numbers here:

9-Digit Bank Routing Number

Bank Account Number

As a convenience to me, I request and authorize you to pay and charge to my account checks drawn on that account by and paya le to the order of Anthem Blue Cross, provided there are sufficient collected funds in said account to pay the same upon presentaton. I understand that the initial payment amount may vary as a result of change(s) during underwriting, and/or subsequent payment amount may vary as a result of change(s) I makeonce enrolled, such as, but not limited to, adding and deleting dependents or moving my residence. I agree that your rights in respect to each such debit shall be the same as if it were a check signed personally by me. I authorize Anthem Blue Cross to initiate debits (and/or corrections to previous debits) frommy account with the financial institution indicated for payment of my Anthem Blue Cross premiums. This authority is to remain in effect until revoked by meby providing you a 30-day written notice. I agree that you shall be fully protected in honoring any such debit. I further agree that if any such debit were to be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever even though such dishonor resuls in forfeiture of insurance. NOTE: Should your withdrawal not be honored by your bank, you will automatically be removed from Monthly Checking Account Automatic Premium Payment and will be billed monthly. You will incur a service charge for any withdrawal not honored.

Authorized Signature (as it appears in the financial institution’s records)

Account Holder Name (Please PRINT)

Date

X

B. Electronic Check – In lieu of sending a Paper Check, we can submit this same information electronically.We will need you to complete the information below. We require an exact amount and check number of the check you are using. Please void this check to prevent future use.

Account Holder Name (Please PRINT)

Bank Routing Number

Account Number

Check Number

Amount

$

C. Credit / Debit Card - As a convenience to me, I request and authorize Anthem Blue Cross to charge my card for a one time initial debit upon approv l. I understand that if this option is selected, my account will be debited for one month of premium as soon as the day of approval. I understand that the initial payment amount may vary as a result of change(s) during underwriting and/or subsequent payment amounts may vary as a result o f change(s) I make once enrolled, such as, but not limited to, adding and deleting dependents or moving my residence. I agree that you shall be fully protected in honoring any such card payments. I further agree that if any such card payment were to be dishonored, whether with or without cause and whether intentionally or inadvertently, you shall be under no liability whatsoever, including any fees imposed by my bank, should my card be rejected even though such dishonor results in forfeiture of coverage. We accept Visa and MasterCard.

I Card Number: I I

I

I

I

I

I

I

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I

I

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___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___ ___

I

Expiration Date:

I

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I/I

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Cardholder Zip Code: I _ _ I _ _ I _ _ I _ _ I _ _ I I

I

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I

Authorized Signature (as it appears on the credit card)

Cardholder Name (as it appears on the credit card – Please Print)

Date

X

  • *

    When you provide a check as payment, you authorize us either to use information from your check tomake a one-time electronic fund transfer from your account or to

process the payment as a check transaction. When we use this information from your check to make an electronic fund transfer, funds will be withdrawn from your

account as soon as the day of approval, and you will not receive your check back from your financial institution. CAPAYFORM-DENTAL Ver.2 11/07/11

Anthem Blue Cross is the trade name of Blue Cross of California. Anthem Blue Cross and Anthem Blue Cross Life and Health Insurance Company are independent licensees of the Blue Cross Association. ® ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. The Blue Cross name and symbol are registered marks of the Blue Cross Association

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