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Group Check It Out Enrollment/Change Form

NOTE: This payment option is not applicable to ASO groups. Please contact your account representative for available payment options.

Required fields are noted with an asterisk *.

For questions, please call .

Enrollment/Change Form

May change due to receipt date
May change due to receipt date

Group Information

As it appears on your bill/invoice

Financial Institution Information

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. 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 signatureName.