Monthly Automatic Payment from your Bank Account.
Monthly Drafts occur on the 15th of the month prior to the coverage month.
By selecting Monthly
Automatic payment, I (we) hereby authorize Wolfpack Insurance Services Inc. to charge the application monthly dues for dental coverage to my account designed below. I understand that coverage will only become and remain effective if there are sufficient funds at the time of the deduction. I understand eligibility begins the first of the month following my initial deduction.
I (We) acknowledge that the origination of ACH transaction to my (our) account must comply with the provision of U.S. Law and the Rules of the National Automated Clearing House Association. I (We) further acknowledge that I (we) have retained a copy of this authorization when I (we) signed it.
You hereby authorize and request Wolfpack Insurance Services, Inc. to debit funds from your account at the financial institution indicated, and credit the funds according to the above instructions. Funds need to be on deposit at the designated financial institution on the evening prior to the effective date of the ACH debit. In the event of an error, you authorize Wolfpack Insurance Servcies, Inc to take any and all action required to correct the error.
You must notify Wolfpack Insurance Services, Inc. in writing if you would like to make any changes or to cancel the authorization.
You agree to indemnify and hold Wolfpack Insurance Servcies, Inc. harmless from all costs, including attorney’s fees, (to the extent permitted by law), damage or claims related to Wolfpack Insurance Services action in refusing payment of the item, including claims of any joint account-holder, payee, or endorsee, or in failing to cancel or process an item as a result of incorrect information provided by you. Upon cancellation Wolfpack Insurance Services will collect any outstanding premium due.
By clicking Submit Form below, you certify that the information you have given on this ACH Debit Authorization Agreement for Direct Payments is complete, true, and submitted for the purpose selected above.
I also understand there cannot be any lapse in coverage in a 12-month period from the time of my enrollment. I agree to comply with the terms outlined in the Combined Evidence of Coverage and Disclosure Form. (My bank is authorized to make corrections if any should be necessary.) Automatic draft failures are subject to a $15.00 fee.
Bank Name: Type of Account: Choose one please
ABA Routing number (First nine digit number on left hand bottom of your check):
Account Number (Second series of numbers on the bottom of the check:
Terms and Conditions
I hereby understand and acknowledge that I am enrolling in the Wolfpack Insurance Services Trust group for DeltaCare
coverage under group 01675, plan 11B. Benefit and plan information was reviewed from the DentalandVisionIns.com web site,
Family Plan Section. I agree to the terms and conditions of the plan.
Click here to view a complete evidence of coverage for this plan.
We will send you a copy of the Evidence of Coverage for Plan 11B along with a wallet card for your use as confirmation that you are
enrolled. The minimum enrollment period is 12 months. Should you voluntarily cancel enrollment and subsequently desired to
re-enroll, all premiums retroactive to the date of cancelation (but not to exceed 12 months) must be paid before you can re-enroll. If
you cancel after your initial 12 months enrollment period and wish to re-enroll you will have to wait 13 months from your last date of
Premium rates renew January 1st of each year and I understand that I will sent a renewal notice to the last known address on Wolfpack
Insurance Services systems. I hereby authorize my medical or dental care institution or professional to release to a representative of
PMI, any personal, privileged or medical records information including, but not limited to, my patient records, charts, x-rays, diagnosis
histories, billing records, clinical abstracts, or copies of consultations. The information authorized herein may be used for determination
of benefits, quality assessment, utilization review, grievance resolution or investigation or compliance with the PMI provider agreements
or local, state or federal laws. This authorization is valid for the duration of coverage.
In addition to the rates shown below, there is a one time enrollment fee of $5.00
Monthly Rates Effective 01-01-2017 to 12-31-2018:
Monthly - One Person $34.20, Two Persons $60.70, Three Persons $89.10
Quarterly - One Person $102.60, Two Person $182.10, Three Persons $267.30
Click here to acknowledge you have ready the above statement:
I agree to the terms and conditions of the plan