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Bank Draft Authorization Form

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

All fields are required unless marked as optional.

Member Information

(xxx-xxx-xxxx for U.S. numbers)
No dashes. Example: 123456789

Bank Information

Please enter your bank's five-digit ZIP code.
(xxx-xxx-xxxx for U.S. numbers)

Payment Options

Select one of the following payment options
Verify your correct routing number and account number with your banking institution.
Check

Disclaimer

I authorize my bank listed above to pay and charge my bank account for checks drawn by and payable to the order of GEHA Connection Dental Plus on a monthly basis as indicated above. I understand that if my signature is required I will be contacted by Connection Dental Plus and must return the signed form for automatic withdrawal to begin. I understand that I will be charged on or before the 5th of the coverage month (or the next business day) by automatic withdrawal. This authorization shall extend to any premium increase effected by the Connection Dental Plus plan under the terms thereof. I understand that I must contact Connection Dental Plus or my bank to cancel this authorization.

Accept disclaimer?

If you need help with this form, or have any questions, please call us at 1-833-434-2988.