Authorization Agreement for Monthly Pre-Authorized Payments
(Please Print)
NAME (as shown on checking account) __________________________________________________
I (we) hereby authorize Insurance Benefit Administrators, hereinafter called COMPANY, to initiate debit
entries to my (our) Checking account indicated below and the depository named below, hereinafter called
DEPOSITORY, to debit the same to such account.
DEPOSITORY
(Bank) Name ___________________________________________ Branch ______________________
Street Address _______________________________________________________________________
City ___________________________________ State ________________ Zip ____________________
9-Digit Routing #: ________________________________________ Account No. ___________________
Bank Phone Number (include area code) ___________________________________________________
This authority is to remain in full force and effect until COMPANY and DEPOSITORY have received written
notification from myself of its termination in such time and in such manner as to afford COMPANY and
DEPOSITORY a reasonable opportunity to act on it.
Name _____________________________________________________ Case Number ______________
Signature __________________________________________________ Date _____________________
Is form filled out completely? Copy of voided check attached?
Insurance Benefit Administrators
P.O. Box 2943, Shawnee Mission, KS 66201-1343
www.insurancebenefitadministrators.com
800-650-1745
655s1118
click to sign
signature
click to edit
![]()
