Information

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Checking Account Verification

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Account Information

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*Last name: Please provide a valid Last name

Financial institution information

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*Checking account number: Please provide a valid Account number

*Routing number of financial institution: Please provide a valid Routing number

Upload Check

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Signature/Authorization

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Automatic Premium Payments allow your insurance premiums to be automatically withdrawn from your checking account each month. Having your premiums automatically withdrawn gives you assurance that your coverage will not be cancelled for late payment or non‐payment. Additionally, it reduces administrative costs and your personal banking costs by eliminating the need to write and mail a check each month. To use this automatic payment method, read the following authorization statements, complete the application information below and upload a VOIDED check.

Automatic on behalf of the named Account Holder, I authorize the University of Pittsburgh and their administrator to begin deductions from the account and financial institution designated, for payment of my premium invoices.

Automatic The financial institution is authorized to charge these withdrawals to my account until you revoke this authorization in writing.

Automatic I agree that I am solely responsible to maintain sufficient funds in the designated account to ensure that monthly premiums can be withdrawn on the tenth day of the coverage month (or first business day thereafter if the twenty‐fifth is on a weekend or holiday). Failure to pay on time can result in additional fees or the loss of applicable coverage.

Automatic I acknowledge that the University of Pittsburgh or the financial institution can terminate this automatic premium payment program or my participation in it at any time, with or without cause

Automatic I affirm that I am duly authorized to execute this Debit Authorization on behalf of the named Account Holder.

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