Fillable ELECTRONIC TRANSFER FOR PAYMENT Small Business

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ELECTRONIC TRANSFER FOR PAYMENT Small Business

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Small Business
718140143 January 2022 ADA
Small Business
ELECTRONIC TRANSFER FOR PAYMENT
INSTRUCTIONS
New Group: Return this form, along with your Employer Application, to your Kaiser Permanente sales representative and/or broker.
Existing Group: For future payments, email this form to csc-sd-sba@kp.org or fax to 855-355-5334. To make a phone payment, call us at
800-731-4661 and choose the Payment Line option.
Note: Kaiser Permanente doesn’t accept credit card payments for small group coverage.
COMPANY INFORMATION
Company name Group ID (if assigned)
Phone
( ) –
Ext. Email
AUTHORIZATION
I authorize Kaiser Permanente to withdraw the amount due, based on the nal enrollment, from the account below:
Bank routing number (9 digits) Bank account number
INITIAL PAY
One-time withdrawal for first month’s payment based on Your Total Premium
Select one:
Save account information for future reference
Do NOT save account information for future reference
RECURRING PAYMENT
Check box only if you would like recurring payments.
Future autopay/recurring payment*
Withdraw statement balance 4 days prior to due date (other options are available at account.kp.org once your account is set-up).
*If selecting autopay, the rst payment will be based on the rst billing statement which can be as much as 2 months, due to billing cycles. If this payment
is returned unpaid, I authorize Kaiser Permanente to resubmit the payment and charge this account an additional insufcient funds fee for the maximum
amount allowed by the state as a result of a returned check.
READ AND SIGN
I afrm that I have authority to contract with Kaiser Foundation Health Plan, Inc. and Kaiser Permanente Insurance Company on behalf of the group.
Authorized company signer (please print name) Company title (please print)
Signature Date
Confidentiality note: This information is intended only for the use of the individual or entity named above. If you’re not the intended recipient, you’re
hereby notified that any disclosure, copying, distribution, or use of the information in the transmission is strictly prohibited. If you’ve received this
transmission in error, please notify the sender immediately by telephone or by return fax and destroy this transmission, along with any attachments.
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ELECTRONIC TRANSFER FOR PAYMENT Small Business

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Completed 25 October 2021

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