Bank Draft Authorization Form

This form is required for monthly or quarterly Bank Draft. Bank Draft is available from a checking or savings account. After we receive your completed form, we will contact your bank to set up the automatic draft for premium payment.

If you prefer to not send this form to us by Email, you can download this form by clicking "Download" above, printing it and mailing it to Connection Dental Plus at the address below or faxing it to 800.257.3358.

Connection Dental Plus
Attn: Connection Programs
P.O. Box 21542
Eagan, MN 55121-9930

In the event your signature is required, we will contact you by mail at the address on file. If you need help with this form, or have any questions, please call us at 800.793.9335.