Uniformed Services Benefit Association  


  1. Please print and complete the Authorization form below. Attach your “VOID” check.
  2. Mail the original to: USBA, P.O. Box 25956, Overland Park, KS 66225-0956.
  3. Keep a copy of the completed form for your records.
  4. Please note: USBA EZ PAY deductions are made on the 1st of each month. USBA will continue making deductions from the account on our records until this form is received and processed. Allow at least 10 days for processing. If deductions from your existing account must stop prior to that time, call USBA’s Customer Service department at (800) 821-7912.
  5. When processing is complete, USBA will notify you of the date and amount of the first withdrawal from your new bank.
  6. On the 1st of every month, log your insurance premium withdrawal amount in your bank account records. Deductions will clear your account on or near the 1st of each month.


I authorize the Uniformed Services Benefit Association, hereinafter called the Company, to make monthly withdrawals in the amount of the premium payment due from my account at the depository financial institution named below, hereafter called Depository. I (we) acknowledge that the origination of ACH (automatic clearing house) transactions to my (our) account must comply with provisions of U.S. law.


Member’s Name:

Social Security #:

Spouse’s Name (if Joint):

Social Security #:


Name of Financial Institution:

Name of Account Holder:

Street Address of Financial Institution:


State: ZIP:

Transit/ABA Number (First 9 digit # between two colons at bottom of check):

Account #    Checking:                                                 Savings:

Terms of Agreement:
I have an account at the depository named and for all withdrawals have funds sufficient to pay such entries upon presentation. The automatic debiting of my bank account is voluntary and will be debited on a monthly basis as long as a statement balance exists. No payment to the Company shall be deemed to have been made until the Company receives actual credit. The Company reserves the right to refuse or terminate automated payment services. This agreement is to remain in effect until the Company receives written notification of its termination and has sufficient time to act on it.

Signature of Account Holder:


Date Signed: