Page 12 - ILA 970

SECTION 4: Insurance Acceptance
Member Signature: _________________________________________________ Date: _________________________ Spouse Signature: __________________________________________________ Date: _________________________
1. Are you actively at work on a regular basis and able to perform the regular duties of you occupation? c Yes c No
2. Are you a member in good standing and able to perform these activites of a person of like age and gender? c Yes c No
SECTION 5: Electronic Fund Transfer Authorization Form
Authorization
The Capitol Group Payroll Services (herein after “the company”) will draft the checking or savings account designated on this form for insurance premiums once the policy has been approved for issue, subject to the terms below.
I understand and agree that the authorization is subject to the following conditions:
• This authorization shall remain in effect until revoked in writing.
• Completion of this form will satisfy the requirement for payment method of the insurance premiums and any applicable administrative fees. • The company will charge an administrative processing fee of $2.00 per ACH transaction in addition to the total monthly premium.
• Use of the selected payment method does not alter any provisions of the policy issued by the insurance company.
• If necessary, refunds of premiums will be refunded by company check or credited via ACH transaction.
• If the payment method selected is not honored upon presentation, the company will make one additional attempt, following this event, for payment. If additional attempt is not hon- ored, the company will terminate any further attempt to use this payment method. The company will charge an administrative processing fee of $15.00 per returned item fee. _________________________________________________________________________________________________________________________________________________ The payor hereby authorizes the company to draft, on a monthly basis, the designated checking or savings account on this form for the initial and subsequent premiums for the policy(s) that have been approved for issue, by Electronic Fund Transfer (EFT); certi es the payor has selected the following nancial institution; and directs all such EFTs be made as provided below.
Bank Account Information for Draft from Checking Accounts or Savings Accounts
Name of Financial Institution:__________________________________________________________________________________________________________________________ Type of Account: c Checking c Savings
Banking Routing Number: c c c c c c c c c Account Number: c c c c c c c c c c c c (First nine digits after check number sequence typically located on bottom left of check) (Must include dashes and spaces as they appear in your account number)
Account Name: ____________________________________________________________________________________________________________________________________ Payor’s Name: _________________________________________________________________________________ Phone Number: _____________________________________
Email Address: _________________________________________________________________________________
Payor will give thirty (30) days advance notice in writing to The Capitol Group Payroll Services of any changes in its nancial institution or other payment instructions. When properly executed, this Authorization will become effective within thirty (30) days after its receipt. The Capitol Group Payroll Services also reserves the right to recall an EFT transaction, if not completed, or incorrect. Before submitting this authorization form, the payor should check with the banking institution to verify it will be able to send/receive Automated Clearing House (ACH) transactions and if there are any associated fees for this service.
***To ensure the correct banking information is entered into our system, please attach a copy of a voided check.***
Date: __________________ Authorized Signature of Payor: ___________________________________________________________________________________________
Step 1 - Complete, sign and date enrollment form. Be sure to include information on all individuals to be covered. Step 2 - Complete, sign and date the payment options form.
Step 3 - Write a check made payable to The Capitol Group for the rst month’s premium.
Step 4 - Return the aforementioned items to:
Local 970 Bene t Center 9609 Gayton Road, Suite 200 Henrico, VA 23238
If you have any questions on the enrollment process or payment options please contact the Local 970 Bene t Center at 757-847-9404.
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ENROLLMENT STEPS