By completing this form, I/we authorize Capital BlueCross and its subsidiaries, Capital Advantage Insurance
Company®, Capital Advantage Assurance Company®, and Keystone Health Plan® Central, and the financial
institution named above, to deduct the amount of the premium for health care coverage from our account
on the designated day and transfer such amount directly to Capital BlueCross.
If the designated day is a holiday, the premium payment will be deducted on the next business day.
I/We agree to maintain sufficient funds in the account to permit these deductions. If the account does
not have sufficient funds at the time of transfer, I/we understand that our Capital BlueCross health care
coverage may be cancelled.
By typing my full name below and submitting this form, I understand that I am creating an "Electronic
Signature" that carries the same legal obligations of a written signature.