Get Payment Authorization & Association Enrollment - Midwest ...

This guide provides a straightforward approach to completing the Payment Authorization & Association Enrollment form online, ensuring clarity and simplicity throughout the process. By following these steps, users can successfully navigate the form and facilitate their enrollment in Dental and Vision products.

Follow the steps to fill out the Payment Authorization & Association Enrollment form online.

1. Press the ‘Get Form’ button to access the form and open it in the editor.
2. Select your payment frequency by marking the box for either monthly or annual payments.
3. Indicate which products you wish to purchase by placing a check next to each selected option. If you are purchasing both dental and vision plans, combine the appropriate premium amounts from the product rate sheet and include the one-time non-refundable enrollment fee to calculate your total first payment.
4. Provide your primary insured/applicant information, including first name, middle initial, last name, and contact details.
5. If the payer information differs from the primary insured, input the payer's first name, middle initial, last name, suffix, and billing address.
6. Choose your payment options. For the initial payment, select either a one-time automatic bank withdrawal, credit/debit card payment, or check/money order. Fill in necessary details according to the selected payment method.
7. For recurring payments, choose your preference for either monthly or annual payments. Complete the necessary banking information or payment details for either automatic bank withdrawal or credit/debit card.
8. Sign and date the Agreement & Signature section to confirm your understanding and authorization.
9. If applicable, sign and date the Association Enrollment section to register for membership. Remember, this is essential for eligibility.
10. Once all sections are complete, save your changes, download, print, or share the form as required. Ensure all documents are mailed to the appropriate address with any applicable fees.

Complete your Payment Authorization & Association Enrollment form online today.