This form is to be used for the Alliance Health Plan and completed by an authorized employer representative.

Employer Bank Information

Employer Name *

Employer Location or Church Code

Employer's Bank Name *

Bank Phone Number

Bank City *

Bank State *

Bank Zip Code *

This account is a *

checking account

savings account

Bank Routing Number (9 digits) *

Bank Account Number * 🛈

Employer Authorization for Automatic Payment

I hereby authorize THE CHRISTIAN AND MISSIONARY ALLIANCE to withdraw funds each month from this account for payment of insurance premiums and HSA contribution elections. Premiums will be withdrawn by the third business day of each month for that month’s coverage.

I understand this authority is to remain in full force and effect until ALLIANCE BENEFITS has received written notification from the employer authorized representative of its termination or change in such manner as to afford THE CHRISTIAN AND MISSIONARY ALLIANCE and employer’s bank reasonable opportunity to act on termination or change request.

Name of Account Holder as Printed on Check *

Authorized Employer's Signature Name *

Employer Title *

Contact Phone Number *

Email Address *

Date * +

Authorized Employer's Signature *

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