Easy Pay from Aetna
13.03.327.1 A (10/07)
Save yourselfthe time andtrouble of billpaying.
13.03.327.1 A (10/07)
©2007 Aetna Inc.
Aetna Advantage Plans for individuals, families and the self-employed are underwritten by Aetna Life Insurance Company(Aetna) directly and/or through an out of state blanket trust.In some states, individuals may qualify as a business group ofone and may be eligible for guaranteed issue, small grouphealth plans.
IMPORTANT — Please read and sign.
Terms of Agreement:
I have an account(s) at thefinancial institution named and, for all debit entries,have funds sufficient to pay such entries. Electronicdebit entries shall be initiated by Aetna Health Inc. topay Aetna plan premiums and other charges for thelisted health care policies or other policies as authorized,and the entries shall constitute my receipt for thetransaction(s). No payment to Aetna shall be deemedto have been made unless and until Aetna receives fulland final credit for the payment. I also understand that ifcorrections to the entry are necessary, they may involvean adjustment to my account. I understand my directelectronic payment of the Aetna plan premium will bedebited on or after the premium due date, the 1st or15th of every month.NOTE: All terms and conditions of the Aetna HealthInc. Group Agreement shall remain in full force andeffect. Aetna reserves the right to refuse or terminateelectronic payment services at any time. This agreement isto remain in effect until Aetna or the member terminatesit. For the termination to be effective and to discontinueelectronic withdrawal, the termination notice needs to bereceived 10 days prior to the next scheduled withdrawal.
Joint accounts require the signature of ALLpersons having authority over the account.Please be sure all joint account holderssign below regardless of who is applying.
Signature X _______________________________________Signature X _______________________________________
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Aetna EFT Application
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| Category: | Uncategorized. |
| Rating: | (1 Rating) |
| Upload Date: | 03/11/2008 |
| Copyright: | Attribution Non-commercial |
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