Please print and complete the Authorization form below. Attach your “VOID”
check.
Mail the original to: USBA, P.O. Box 25956, Overland Park, KS 66225-0956.
Keep a copy of the completed form for your records.
Please note: USBA EZ PAY deductions are made on the 1st
of each month. USBA will continue making deductions from the account on our
records until this form is received and processed. Allow at least 10 days for
processing. If deductions from your existing account must stop prior to that
time, call USBA’s Customer Service department at (800) 821-7912.
When processing is complete, USBA will notify you of the date and amount of the
first withdrawal from your new bank.
On the 1st of every month, log your insurance premium withdrawal
amount in your bank account records. Deductions will clear your account on or
near the 1st of each month.
AUTHORIZATION FOR AUTOMATIC PAYMENTS
I authorize the Uniformed Services Benefit Association, hereinafter
called the Company, to make monthly withdrawals in the amount of the premium
payment due from my account at the depository financial institution named
below, hereafter called Depository. I (we) acknowledge that the origination of
ACH (automatic clearing house) transactions to my (our) account must comply
with provisions of U.S. law.
MEMBER INFORMATION
Member’s Name:
Social Security #:
Spouse’s Name (if Joint):
Social Security #:
FINANCIAL INSTITUTION INFORMATION
Name of Financial Institution:
Name of Account Holder:
Street Address of Financial Institution:
City:
State:
ZIP:
Transit/ABA Number (First 9 digit # between two colons at bottom of check):
Account # Checking: Savings:
ADDITIONAL INFORMATION
Terms of Agreement: I have an account at the
depository named and for all withdrawals have funds sufficient to pay such
entries upon presentation. The automatic debiting of my bank account is
voluntary and will be debited on a monthly basis as long as a statement balance
exists. No payment to the Company shall be deemed to have been made until the
Company receives actual credit. The Company reserves the right to refuse or
terminate automated payment services. This agreement is to remain in effect
until the Company receives written notification of its termination and has
sufficient time to act on it.
