Get Direct Draft Form - State Of West Virginia - Peia Wv

Completing the Direct Draft Form for the State of West Virginia's PEIA program online is a straightforward process that simplifies your monthly premium payment. This guide will walk you through each section of the form to ensure you provide the necessary information correctly and efficiently.

Follow the steps to successfully complete your Direct Draft Form online.

1. Press the ‘Get Form’ button to access the Direct Draft Form and open it for input.
2. Fill in your personal information in the section labeled 'Policyholder Information.' This includes your name, address, city, state, zip code, and phone number.
3. Proceed to the 'Financial Institution Information' section. Here, provide the institution name, address, city, state, and zip code of your bank or financial institution.
4. Select the account type you wish to use by checking either 'Checking' or 'Savings.' Ensure you have your routing number and account number ready for input.
5. Indicate the date you wish for your premium to be debited each month by checking the appropriate option.
6. Authorize the draft by signing and dating the bottom of the form. Ensure that you attach a voided check for verification if you selected a checking account.
7. Once all sections are completed, save your changes. You may download, print, or share the form as needed to ensure it is submitted properly.

Start completing your Direct Draft Form online today to enjoy hassle-free payments!