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 applicable monthly dues for dental coverage to my account designated 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:
ABA Routing number (First nine digits number on left hand bottom of your check):
Account Number (Second series of number on the bottom of the check):