SABC Online Enrollment for STATE OF MISSISSIPPI RETIREES for the period 07/15/2020 to 07/14/2021

State of Mississippi Retiree DENTAL



mm/dd/yyyy
mm/dd/yyyy
, city, state, zip
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Yes
No





Bank Information

This will be used to debit premium payments for your insurance.

Please debit my account:

Monthly   Quarterly   Semi-Annually   Annually

I hereby request and authorize the Financial Institution named above to pay my obligation by charging each payment to my account and to make the deduction payable to the order of MWG Administrators. I agree each payment shall be the same as if it were an instrument personally signed by me. This authorization will remain in effect until revoked by me in writing. In addition, I have the right to stop payment of a charge by timely notification to my Financial Institution prior to charging my account. I understand, however, both the Financial Institution and MWG Administrators reserve the right to terminate this payment plan (or my participation therein). If the premium amount changes, I will be notified in writing prior to any changes in the amount deducted from my account. Payments will be debited from this account at the frequency and date agreed upon by the accountholder and MWG Administrators.


MWG Administrators will send a notice of payment not honored. Payments not honored will not be submitted a second time. If a payment is not honored, my insurance coverage will terminate on the last paid through date. If I wish to continue my insurance after a payment is not honored, MWG Administrators must receive full payment for any outstanding balance prior to the end of that month. MWG Administrators will charge a $20.00 fee in addition to any bank charges. Reinstatement is only possible within 30 days of the not honored payment after which no reinstatement is possible. After two payments are not honored, reinstatement is not possible.

(THE FOLLOWING FIELDS ARE REQUIRED)

Account Type: Checking     Savings

Financial Institution Name

Financial Institution City and State
 
Financial Institution Routing/Transit (ABA) Number

Deposit Ticket numbers cannot be used.
Your Account Number

Please double check the FDIC Bank Routing/Transit and your bank account number for accurate entry.

Select Your DENTAL Coverage Option:

List all your Eligible Dependents that are to be covered for DENTAL


I wish to enroll in the plan indicated above. I understand and agree to the terms and conditions listed on this form.

08/07/2020
Your 9-digit SSN, Digits Only