Premium Payment Form

Automatic Premium Payment

Automatic Premium Payment Enrollment and Update Form

Use this form to enroll in or update automatic premium payments on your HealthPartners policy. When you enroll in auto pay you’ll no longer receive a paper invoice. Visit your healthpartners.com account to view invoices.

Policyholder Information

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Coverage Information

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Bank Information

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Conditions of Acceptance

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POLICYHOLDER INFORMATION

Policyholder information must be completed.

Last name

First name

Middle initial

HealthPartners member number

Date of birth

Preferred telephone number

Alternate telephone number

Current Date

COVERAGE INFORMATION

Provide information on the plan(s) that you would like to enroll or update automatic payments on.

Medical Plan Contract Number

Dental Plan Contract Number

Request received after the 20^th of the current month may not be effective until the following month. Requests to stop auto pay must be received by the 20^th of the current month.

BANK INFORMATION

Provide the information for the bank account you would like your premium payments withdrawn from. Payments will be withdrawn on the first business day of the month.

Is the policyholder is same as Bank account holder?

Select one:

Personal checking account

Personal savings account

Bank account holder’s name*

Bank name*

Bank routing number (9-digit)*

Bank account number*

Confirm Bank account number*

*These numbers are at the bottom of your check:

Personal accounts are recommended for automatic withdrawals. Business accounts may have restrictions on electronic deductions which may cause withdrawals to be returned as not paid.

CONDITIONS OF ACCEPTANCE

Policyholder and account holder (if different from the policyholder) must sign below.

I authorize monthly withdrawals from my bank account to pay monthly insurance premiums for the policyholder named above. Requests to stop or change ongoing automatic payments must be received by the 20th of the current month. I understand that fees or rate increases may change the monthly premium, and I authorize the withdrawal of these additional amounts. I understand any past due premiums will be withdrawn within 3 business days of receipt of this form. I agree to pay all charges associated with any payment returned by the bank. If I am not the named policyholder, I understand that I will not have access to or any authority to take action on this insurance policy. I understand that HealthPartners requires authorization from the policyholder to change or discontinue automatic payments. I understand that the policyholder will have access to my bank information and receive any refunds related to this coverage.

By signing this form you understand this form may be executed by any form signature, including electronically, allowed by law.

Digitally signed by policyholder

Date

Digitally signed by accountholder

Date

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