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.
AUTOPAY PROGRAM
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:
(Re-Enter)
Type of Account:
Checking
Savings
Financial Institution Name:
Address:
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.
Initials: