Employer Payment Authorization

Provide authorization for a one-time payment and/or update reoccurring payment options.

Authorization*
One-time payments can be used to replace a missed payment or any other balance owed. You may select both a one-time payment and reoccurring payments if applicable.
- One-time payment
- Reoccurring payments
One-time payment amount*
Reoccurring Payments*
Planstin will process reoccuring payments for monthly amount due. Payments will be on the first of each month.
- I agree to allow Planstin to process monthly payments as enrolled.
Additional Instructions
- Yes, I have additional instructions to provide.
Additional Instructions
Please include any additional instructions needed if not already provided.

Account Type*
IMPORTANT: Additional fees apply to card transactions.
- Checking
- Credit Card
Card Number
Expiration Month
Expiration Year
Security Code
Cardholder Name
Name of Bank
Bank State*
Name on Account*
Routing Number*
Account Number*
Authorization*
- I authorize Planstin Inc and Planstin Administration Solutions to charge my bank account indicated above for my enrolled benefits. Returned payments are subject to a $25 returned payment fee.
Processing Fee*
- I accept the processing fee of 3% of the one-time payment.
Signature*
Name*