Health Net of California, Inc., and Health Net Life Insurance Company are subsidiaries of Health Net, LLC. Health Net is a registered service mark of Health Net, LLC. All rights reserved.
FRM029241EC00 (5/19)
Applicant information – Electronic debit payment authorization
Policyholder name: ______________________________________________Group number: ____________________________________ (Health Net use only)
(Must match the name on the master application)
I authorize Health Net to debit my account for the first month’s premium only upon approval of the attached application. This
payment will be electronically debited from my company bank account, using the information provided, based on the copy of the
check below, for
Amount of premium: _____________________________________________________Check number: _________________________________________________________
Transit routing number: _____________________________________________ Account number: _________________________________________________________
Checking account address: __________________________________________________________________________________________________________________________
This transaction will appear on your next bank statement as an electronic funds transfer (EFT) transaction.
If this item is returned unpaid, I authorize a returned check fee for the maximum amount as allowed by the state to be charged to this
account. I also acknowledge that Health Net will not be responsible for any fees incurred if the original check is mailed and cashed.
_____________________________________________________________________________________________________________________________________________________________
Employer signature Title Date
Attach copy of voided check
IMPORTANT: DO NOT MAIL OR ATTACH ORIGINAL CHECK
The Billing Department needs the most accurate information to debit your account. Therefore, the voided check is necessary for
processing. Please note: We are unable to accept the following checks and account types: third-party checks, credit card
checks, cashier’s checks, money orders, traveler’s checks, official checks, government checks.
Confidentiality note: The documents accompanying this facsimile transmission may contain confidential information. The information is intended only for the use of the
individual or entity named above. If you are not the intended recipient, or the person responsible for delivering it to the intended recipient, you are hereby notified that any
disclosure, copying, distribution, or use of the information contained in this transmission is strictly prohibited. If you have received this transmission in error, please notify the
sender immediately by telephone or by return fax and destroy this transmission, along with any attachments.
Electronic Check Form
For new business groups
PLEASE ATTACH
COPY OF VOIDED CHECK HERE
Health Net of California, Inc. and
Health Net Life Insurance Company (Health Net)
