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Automatic Premium Payment Authorization (APPA) Form

  1. Information
  2. Checking Account Verification
  3. Signature/Authorization

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Please complete all required fields below to ensure your form is processed promptly. Fields marked with * are required.

Checking Account Verification

Fields marked with * are required.

Account Information

Financial institution information

Upload Check

Please upload an image of the voided check.


Please acknowledge the following information before signing. Fields marked with * are required.

Thank you for your submission

Your request for automatic premium payments has been submitted. You will receive an email confirmation when your form has been processed which will include the first automatic payment deduction date. Submissions of completed form and voided check received by the 10th of the month will be effective the 25th of the same month. Otherwise, the effective date will be with 25th of the following month. Please continue to pay your premium until notified your form has been processed.

If you have questions about your request, please contact UPMC Benefit Management Services at 1-888-499-6885.