I understand that by
signing this form I am authorizing the necessary premium deductions via
EFT from a designated account.
I will click “Print” below and fax both this completed, signed and dated form and a copy of a voided check (for premium deductions) to
I will complete section E. and click “Submit” below to electronically submit my enrollment and payment information.
I understand that the attached voided check authorizes a monthly premium deduction for selected coverages.
_______________________ _________________________________ __________________
Signature of Applicant Signature of Agent (if paying staff premiums) Date
Your browser does not support inline frames or is currently configured not to display inline frames.