Bank Account Change Automatic Payment Withdrawal
Name: ____________________________________________________________________ Daytime Telephone Number: _______________________________
Address: _______________________________________________________________________________________________________________
New Address
Bill Account/UMI: _________________________________________________________ Requested Eective Date: ___________________________________
Name of Financial Institution: ___________________________________________________________________________________________________________
Address of New Financial Institution:
Account Number: ____________________________________________________________________________________________
Checking Savings
New ABA (Bank Routing) Number: _______________________________________________ Is this a Business Account? Yes No
I hereby authorize my Financial Institution to deduct the current premium from my checking or savings account and remit the same to BCBSND. This
authorization is to continue in eect until revoked by me in writing. I understand a 30-day notice is needed when canceling an automatic withdrawal
authorization. BCBSND is not responsible for overdrafts and fees due to insucient funds in “my account” used on this Account Withdrawal Notice.
Signature: _________________________________________________________________ Date: _______________________________________________________
Bank Account Change Card & Automatic Payment Withdrawal
Please attach a voided check and return to:
Blue Cross Blue Shield of North Dakota, 4510 13th Ave S, Fargo, ND 58121
Blue Cross Blue Shield of North Dakota is an independent licensee of the Blue Cross & Blue Shield Association 29381862 • POD 6-20
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