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 premiums for my child's health coverage from my account.
I 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 understand that my child's 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 signatureName.