AARP Medicare Supplement Application - Colorado Health Agents

Save $24 a year with the
Electronic Funds Transfer (EFT) service
The easiest way to pay.
More than 2.5 million AARP members nationwide enjoy the convenience of the automatic payments
option. With EFT, your monthly payment will automatically be deducted from your checking or
savings account. Also, you’ll save $2.00 off the total monthly rate for your household.
In addition to saving up to $24.00 a year:
• You’ll save on the cost of checks and rising postal rates.
• You don’t have to take time to write a check each month.
• You don’t have to worry about mailing a payment if you travel or become ill, because your
payment is always deducted on or about the fifth day of each month.
Sign Up in Two Easy Steps
1. Complete both sides of the Automatic Payment Authorization Form below. Return it with
the application and be sure to keep a copy for your records.
2. Include a voided check for the checking account from which you want your payments
withdrawn. The information on your check is needed to process your request for EFT.
Do not send a deposit slip or cancelled check.
Your Automatic Payments Effective Date
If you are submitting this EFT form with your enrollment application, your automatic payments start
date will be equal to your plan effective date. A letter will be sent to confirm this and will include the
amount of your withdrawal. Please note that if your coverage is effective in the future or your account
is paid in advance, EFT withdrawals will begin for the next payment due. If your account is effective in
the past or is past due, a letter will be sent that explains how to make the payment that is due.
BA9957A (10-12)
Cut along the dotted line.
AUTOMATIC PAYMENT AUTHORIZATION FORM
I allow UnitedHealthcare Insurance Company
(UnitedHealthcare Insurance Company of New York,
for New York residents), hereafter named UnitedHealthcare,
to take monthly withdrawals, for the then-current
monthly rate, from the account named on this form.
I also allow the named banking facility (BANK) to
charge such withdrawals to this account.
Member Name __________________________
Member Address_________________________
City ___________________________________
State ________________ Zip Code __________
Bank Name _____________________________
Bank Routing No. ________________________
Bank Account No. ________________________
Account Type: Checking
Savings (statement savings only)
The reverse side of this form must also be completed.
0000001 0000034 0067 0074 UMS1129 01 L