Benefit Design Group

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*Company Name:
Customer Number (If known):

I (we) hereby authorize BENEFIT DESIGN GROUP, hereinafter called COMPANY, to initiate debit entries to my (our) Checking Account indicated below at the depository named below, hereinafter called DEPOSITORY, to debit the same to such account.

*Depository Name:
*Branch:
*City:	*State:	Zip:
*Routing Number:	*Account Number:

This authorization is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY and DEPOSITORY a reasonable opportunity to act on it.

*Name(s):
For BDG use only:
Signature:	*Date:	e.g. 02/14/2000

This arrangement does not change the premium due dates specified in the policy and it does not extend any of the grace or late periods for paying these premiums. The policy or policies will be placed on withhold care at the end of the grace or late period if the premium remains unpaid. This could occur if balances in your account were not sufficient to cover the debit amount.

BDG may stop the arrangement by written notice to you. The arrangement ends on the day BDG mails the notice.

If this agreement ends you will still be responsible for unpaid premiums which remains outstanding.

Submission of this form will allow Benefit Design Group, LLC to process the information contained in this document. The Employer agrees to maintain a signed copy of this document. Benefit Design Group, LLC, reserves the right to request a copy of the signed document at any time from the Employer.



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