I hereby authorize Delta Dental of Illinois to charge/deduct
the premium amount as stated on the enclosed bill from the listed
credit card or bank account on or about the 27th of each month for
my monthly premium payment (if the payment method selected is
monthly). I understand that the initial credit card charge or ACH
debit to my account will occur immediately and if I have selected
an annual payment option, the initial credit card charge or ACH
debit will reflect the annual premium.
I agree that this authorization will remain in full force and
effect until Delta Dental of Illinois has received written
notification from me that I am terminating it. I agree to notify
Delta Dental of Illinois in writing of any changes to my account
information or termination of this authorization at least three (3)
days (for ACH debits) or twenty-five (25) days (for credit card
charges) prior to the next billing date. If I have enrolled on the
Individual Marketplace, I understand that the cancellation notice
must be initiated through the Individual Marketplace website.
I understand that Delta Dental of Illinois will notify me in
advance of any changes to the premium amount. By completing this
form, I hereby authorize Delta Dental of Illinois and the credit
card company or bank identified below to process the credit card
charges or ACH debits authorized here.
If I am not the insured person under this policy, I confirm
that I am agreeing to pay this insurance premium on behalf of the
insured person. Unless the insured person is a minor for whom I am
a parent or legal guardian, I understand that any changes to the
policy that may affect the premium amount will be communicated to
the insured person only.
I agree that if I have any problems or questions regarding
this authorization or my insurance policy, I will contact a Delta
Dental of Illinois Consumer Direct Representative at 877-824-2776,
8:30 a.m. to 5:00 p.m. central time, Monday through Friday or by
email at email@example.com. I also agree that I will not
dispute any charges with my credit card company or bank without
first making good faith effort to resolve the dispute directly with
Delta Dental of Illinois. I guarantee that I am the account holder
for this bank account (for ACH debits) or legal card holder (for
credit card charges) and that I am legally authorized to enter into
this Recurring Credit Card Charge/ACH Debit Authorization Agreement
with Delta Dental of Illinois.
For payment by credit card only: I authorize Delta Dental of
Illinois to make any charges on a future policy I may purchase from
Delta Dental of Illinois on the same credit card if I give verbal
consent to Delta Dental of Illinois. Further, I understand that any
transaction that is dishonored by my credit card company intended
for payment to Delta Dental of Illinois may be assessed a $25
service charge by Delta Dental of Illinois.
For payments by bank account only: If my financial
institution rejects an ACH debit from Delta Dental of Illinois due
to insufficient funds, I understand and agree that Delta Dental of
Illinois may in its discretion attempt to process the charge again
within 30 days. I understand that if my bank dishonors any ACH
debit requested by Delta Dental of Illinois under this agreement,
Delta Dental of Illinois may assess me a $25 service charge, and
Delta Dental of Illinois may collect that service charge by means
of an ACH debit. I also understand that Delta Dental of Illinois
may apply that service charge each time it resubmits an ACH debit
request that is rejected (even if it is for the same unpaid amount
as a previously-rejected ACH debit request).
*Do you accept these terms?