Administration ACH or Credit Card Payment

By completing this form, you are authorizing BASIC Benefits to obtain payment for startup and ongoing administrative fees. Auto-pay will remain in effect until BASIC Benefits receives notification canceling it or updating us with a different payment form in writing.

Optional Memo

Invoice Number*

Client ID Number

Please list if known.

Invoice Amount

Payment Frequency*

One-Time Payment
On-Going Payments

New or Update*

Is this an update to a previously submitted on-going payment?

Yes, this is updated payment information
No, this is our first payment submission

Payment Type*

ACH Payment
Credit Card Payment

Company Name*

Authorized Representative*

Title*

Phone*

Representative Email*

Enter Email Confirm Email

Authorized Signature*

Auto-Pay via ACH Payment

Bank Name*

9-Digit Routing Number*

Account Number*

Our Bank Code ID: 1382883561

Auto-Pay via Credit Card Payment

Cardholder's Name*

Type of Credit Card*

Visa
MasterCard
AmericanExpress
Discover

Credit Card Number*

CSV*

Expiration Month*

Expiration Year*

Billing Zip Code*

ZIP / Postal Code

Email Address for Credit Card Receipts*

Enter Email Confirm Email

Note: receipts will come from our Credit Card Merchant

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