I. GUIDELINE STATEMENT
It is in the best interest of Georgia Highlands College to implement Direct Debit for both financial and administrative reasons. Direct Debit allows retirees the benefits of paying their insurance premiums electronically by directly debiting the premium from their chosen account(s).
According to the University System’s Business Procedure Manual, “effective January 1, 2006, the option of direct debit shall be offered to all University System of Georgia retirees who elect, and are eligible, to continue coverage under University System of Georgia health and dental plans and supplemental life insurance coverage”.
a. Obtain an Authorization Agreement for Automatic Debits form from the Business Office or Human Resources department.
b. Attach a voided check to the form (no Debit slips). The check will be used to obtain the account number and bank routing/transit number.
c. Return the completed form to the Business Office.
d. Not have to complete a new form due to insurance premium increases. The increased amount will be debited from the chosen account on the date designated by the System Office. Retirees will receive prior written notification from Human Resources concerning all insurance premium increases or changes.
III. Making Changes to Direct Debit
a. To direct the Debit to a different financial institution and terminate the old institution, the retiree should provide the new information to the Business Office ten (10) days prior to the date on which the change will be effective.
b. To change accounts within the same financial institution, an employee should provide the new information to the Business Office least ten (10) days prior to the desired scheduled change date.
c. The direct Debit will continue to be sent to the designated account(s) until the employee provides other instructions to the Business Office. If the Debit is rejected for Non Sufficient Funds (NFS), GHC will collect such debit(s) and an NSF fee of $30 per item by electronic debit from the identified account. This authorization will remain in effect until GHC receives written notification from the holder determining account termination within 10 days of anticipated of the next transactions.
GEORGIA HIGHLANDS COLLEGE
INSURANCE PREMIUM AUTHORIZATION AGREEMENT
FOR DIRECT DEBIT/BANK DRAFT
OPTIONS ADD CHANGE CANCEL
CITY: STATE: ZIP:
ACCOUNT TYPE: CHECKING SAVINGS
FINANCIAL INSTITUTION NAME:
INITIAL AMOUNT TO DEBIT EACH MONTH:
I authorize Georgia Highlands College to initiate debit entries equal to my monthly insurance premium and, if necessary, initiate adjustments entries to correct errors, yearly increases or other situations that would incur rate changes to the above financial institution. Entries will occur on the 10th of each month. I have attached a voided or cancelled check with my name and financial institution. According to guidelines, I, or an authorized representative, will notify Georgia Highlands College in sufficient time to modify the payment instructions should I change banks, account numbers or otherwise need to cease payments. If the Debit is rejected for Non Sufficient Funds (NFS), I authorize GHC to collect such debit(s) and a NSF fee of $30 per item by electronic debit from the identified account. This authorization will remain in effect until GHC receives written notification from the holder determining account termination within 10 days of anticipation of the next transaction. I understand that Georgia Highlands College reserves the right to terminate this payment method and my participation in this service, if necessary.
Printed Name: ____________________________________________________
Please attach voided check here: