Follow the steps to complete the form accurately.

1. Press the ‘Get Form’ button to access the form and open it in the designated editor.
2. Read the authorization agreement for automatic bank withdrawal carefully to understand its importance and terms.
3. Complete, sign, and date the authorization section to confirm your agreement. You can cancel your automatic withdrawals anytime, provided you notify in writing at least 20 days before the next scheduled withdrawal.
4. Indicate whether you are starting, updating, or stopping your automatic bank withdrawal by checking one of the options provided.
5. Specify the month you wish to implement this change by filling in the format MM/YY.
6. Provide your policyholder information, including the type of insurance plan (individual or employer group), policyholder name, policy or member number, or Social Security number as necessary.
7. Enter your email address for communication purposes.
8. Choose the type of bank account you are using (checking or savings) by selecting the appropriate option.
9. Provide the name of your bank and the city in which it resides, along with the state.
10. Fill in the name on the bank account, bank account number, and nine-digit routing number, if available.
11. As the authorized bank account holder, sign and date the section confirming your authorization of DAKOTACARE to initiate debits for your premium payments.
12. Review all entered information for accuracy before finalizing the form.
13. Once completed, you can either mail or fax the form along with a voided check or copy of a check, to the provided addresses.

Begin filling out the form online today for a seamless experience with your premium payments.