HBTF Insurance Banking Authorization Form

Banking Authorization/Change Form

Monthly withdrawal for HBTF Insurance premiums
Name*

First NameLast Name
Doctors of BC #
Email*

Confirmation Emailexample@example.com
I/We hereby authorize Doctors of BC to withdraw the premiums for the programs indicated below from the bank account(s) designated on this form, and if applicable, I/we authorize the change of my/our existing bank account records with the new information provided on this form.

For information related to privacy of the information collected, please see Doctors of BC Privacy Policy.
Select account for which you are authorizing Direct Debit

Personal AccountCorporate Account (incorporated)Business Account (non-incorporated)
NOTES:
1. HBTF Health and Dental includes both monthly premium as well as Cost-Plus claim withdrawal (if enrolled in Cost-Plus)
2. HBTF Health and Dental may also include life and accidental death premiums if it is part of your HBTF plan (applies to all eligible employees and physicians enrolled prior to 2014). If this is the case, do not select AD&D and Life insurance - they will be updated as part of the HBTF banking update
3. If you are choosing Corporate Account, please include certificate of incorporation.
Are you authorizing premium withdrawals from a new bank account or a bank account already on file with Doctors of BC?*

New Bank AccountExisting Bank account
New Bank Account:*
Upload proof of New Bank Account *

void cheque, photo of void cheque, or banking deposit form are acceptable forms of proof.
Cancelof
Upload Certificate of Incorporation *

If adding a new corporate account, please also include the certificate of incorporation.
Cancelof
Existing Bank Account:*
Do you want to update your HBTF Cost-Plus Claims Deposit Bank Account? ⓘ*

YesNo
Cost-Plus
Is this a new bank account or a bank account already on file with Doctors of BC? ⓘ*

New Bank AccountExisting Bank account (either submitted as part of this form or previously)
New Bank Account:*
Void Cheque upload*

void cheque, photo of void cheque, or banking deposit form are acceptable
Cancelof
Existing Bank Account:*
I/We hereby authorize Doctors of BC to deposit the the Cost Plus Claims to the bank account designated above, and if applicable, I/we authorize the change of my/our existing bank account records with the new information provided on this form.

For information related to privacy of the information collected, please see Doctors of BC Privacy Policy.
Signature*

Clear
Should be Empty:

Banking Authorization/Change Form

Cost-Plus