Superior Dental Care Secure Form
Use this form to sign up for our convenient AutoPay program, which allows your group to have your
SDC premium payments automatically deducted from the account of your choice.
We hereby authorize Superior Dental Care to initiate debit entries to our account indicated below at the financial institution named below.  
Company Name:  
Group Number:
Name on Account:  
Account Number:
Type of Account:
Financial Institution Name:  
Routing and Transit Number:  
Please use our Document Upload to securely send a copy of a voided check (required).
By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.
This authorization will remain in full force and effect until Superior Dental Care has received written notification of any and all changes 30 days prior to change date and in such a manner as to afford Superior Dental Care and bank to act upon it.