Please print a copy
of this completed form after submission and mail it along with a void cheque
National HealthClaim Corp.
335 58th Avenue SE
Canada T2H 0P3
Monthly Debit Authorization Form: I (we) authorize National HealthClaim and noted Financial Institution to withdraw funds from my (our) business account for the purpose of paying FBC InsurPak premiums. A debit in paper, electronic or other form may be drawn on my (our) account beginning the 15th day of the month after the enrollment has been signed. This agreement may be cancelled by either me (us) or National HealthClaim in writing, with at least 2 weeks (14 days) prior to the first day of the following month. I (we) also understand that should any withdrawal not clear my (our) account for reason of insufficient funds, National HealthClaim will automatically attempt to withdraw these funds within 10 days of the returned item without prior notification.
FBC InsurPak coverage is effective the first day of the month following the receipt and approval by National HealthClaim. I authorize National HealthClaim to process a monthly debit on my (our) account for the amount determined by the number of single and family employees on the system by the first day of each month.