Oscar: ACH Authorization Form
Bank name
Account type
Checking
Savings
Account number
Conrm account number
Routing number
Account numberRouting number (9 digits)
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account you chose in the section above.
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I hereby authorize Oscar Insurance Corporation, including its parent, afliates and subsidiaries (Oscar) to initiate entries to the checking/savings
account at the nancial institution listed above, and, if necessary, initiate adjustments for any transactions credited/debited in error. This authority
will remain in effect until Oscar noties me that this service has been discontinued, or I notify Oscar in writing to cancel it in such time as to afford
Oscar and the nancial institution a reasonable opportunity to act on my request. I agree to notify Oscar in writing of any changes in my account
information at least 15 days prior to the next billing date. If payment dates fall on a weekend or holiday, I understand that the payments may be
executed on the next business day. I understand that ACH debits to the checking/savings account are electronic transactions and funds may be
withdrawn from the account as soon as the above noted periodic transaction dates. I certify that I am an authorized user of this credit card/bank
account and will not dispute these scheduled transactions with my bank or credit card company as long as the transactions correspond to the terms
indicated in this authorization form.
Billing contact (print full name)
Group number (if available)
Business name
ACH Authorization Form
Section A: Business billing information
Section B: ACH account information
Section C: Payment settings
Section D: General agreement
Signature of applicant Printed name Date (mm/dd/yyyy)
Sign here
Fill out the following form to allow Oscar to store and debit payments from your bank account. By submitting this form you are authorizing Oscar to
debit the rst month’s full premium automatically upon approval. Subsequent payments will be deducted automatically only if auto-pay is selected.
ACH payments are easy and will help get your employees their member ID cards faster and easier!
click to sign
signature
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