I hereby authorize EMI Health to withdraw the total or amount specified as the premium payment from my account. If recurring payments are selected they will take place on the fifth day of each month, or the first business day thereafter. This authority is to remain in effect until EMI Health has received written notification from me thirty days prior to the next scheduled electronic premium payment, or until I receive written notification of termination from EMI Health. Changes to the withdrawal account and/or failed withdrawals may be subject to an additional administrative fee. Refunds are not permitted unless coverage is terminated 5 days prior to the effective date.
Please allow up to 48 hours for this payment to be reflected on your account.