Company Setup

Payment Method*

Our preferred method of payment is using your business checking account and there is no fee for this option. If you choose to pay using credit card, there is an additional 3% processing fee. If you choose to be invoiced there is an additional $25 fee.

Checking/Saving
Credit Card
Invoice Billed

Annual Billing

By participating in annual billing you would pay the enrolled benefits in full for the year. By doing so you do not get charged a setup fee or invoice fees. Your rates also are locked in for the year provided that you do not change coverage. If you select annual billing you will get a separate email with payment instructions as an invoice.

Yes. I would like to pay for the year in full with annual billing.

Setup Fee Billing Option*

How would you like to pay for the setup fee?

Checking Account
Credit Card

Card Number*

Expiration Month*

Expiration Year*

Security Code*

Cardholder Name*

Account Name*

What name is the account in? (Ex: "ABC Sample Business" or name of sole proprietor)

Routing Number*

Account Number*

Authorized Account Holder*

By typing your name below you are giving payment authorization for initial and monthly payment of enrolled plans. I understand that this authorization will remain in effect until I cancel it in writing, and I agree to notify Planstin Inc in writing of any changes in my account information within 15 days. This payment authorization is required for plan administration. In the case of an ACH or Credit Card Transaction being rejected for Non-Sufficient Funds (NSF) I understand that Planstin Inc or its assigned third party may at its discretion attempt to process the charge again within 30 days, and agree to an additional $25 charge for each attempt returned. I acknowledge that the origination of ACH transactions to my account must comply with the provisions of U.S. law. I agree not to dispute this recurring billing so long as the transactions correspond to the terms indicated in this authorization form.

Yes, I agree

Monthly Payment*

Enrollment of employees are to be completed after the company setup. Once completed you will receive additional instructions for each employee to enroll in benefits.

I authorize the monthly payments of plans that are enrolled for our company.

Group Setup Fee*

I authorize the setup fee of $150.00 to be charged to the account provided. The setup fee is processed immediately.

Invoice Fee*

I authorize the monthly invoice fee of $25.00. Invoices are sent by email and monthly payments are due on the first (1st) of each month. If I am late I understand that there is a $25 late fee.

Credit Card Processing Fee*

I authorize the credit card processing fee to be added to the monthly invoice. This charge is an extra 3% of the total monthly invoice of the benefits enrolled. This extra charge does not apply to the setup fee.

Group Setup Fee Applied

Group Setup Fee Waived

Name

First Last

Signature*

Step 1 of 4