Page 45 - The Technician October-November 2017 Flip Book

SECTION 3: Short-Term Disability Income Insurance Underwritten by Transamerica Life Insurance Company
Please select a benefit amount not to exceed 60% of your monthy income but no greater than $3,000, whichever is less.
c 6 Month Benefit $______________ Monthly Benefit Amount c 12 Month Benefit $______________ Monthly Benefit Amount Disability Income Insurance Premium $______________ Disability Income Insurance Premium $______________
c 24 Month Benefit $______________ Monthly Benefit Amount Disability Income Insurance Premium $______________
DISABILITY INCOME INSURANCE PREMIUM $______________
PREMIUM TOTAL (Transfer total to ACH form below) $______________
SECTION 4: Electronic Fund Transfer Authorization Form
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?
2. Are you a member in good standing and able to perform these activites of a person of like age and gender?
Authorization
c Yes c Yes
c No c No
$ ___________._____Total Monthly Premium
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.
• Signing this authorization does not mean that coverage is effective. Coverage is effective only as stated by the insurance company.
• 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 honored, 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); certifies the payor has selected the following financial 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)
$_________________Total Monthly Preium 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 financial institution or other payment instructions. When proper- ly 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.***
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 first month’s premium.
Step 4 - Return the aforementioned items to: ACT Benefit Center 9609 Gayton Road, Suite 200 Henrico, VA 23238
If you have any questions on the enrollment process or payment options please contact the ACT Benefit Center at 844-236-1002.
ENROLLMENT STEPS