Automatic Payment (ACH) Request Form

The fastest and easiest way to make your payments, or to review your account at any time, is to access your account on our Member Portal.

Member Portal Submission Recurring ACH

You select the date that you want the ACH to process and when the charge will hit your bank account
If multiple payments are due to bring the account paid to current you may select the date for each true-up payment transaction
ACH detail is updated live time and forecast of scheduled ACH pull is made available so you know when each payment will process

Form Submission Recurring ACH

Payments will process based on the due date of your payment coupons
If multiple payments are due to bring the account paid to current, the same date is used for lump-sum payment of all true-up payment transactions along with current premium due
Please allow 3-5 business days for processing of this request while our team manually updates your account with form submission detail

How would you like to manage your ACH payment transactions?*

Electronically via Member Portal/ Real time Form Submission/ 3-5 Day Processing

Reason for ACH Form Submission*

Add New/ Set-up Recurring ACH for Premium Payments Change ACH Payment Information Cancel/ End Recurring ACH Payments

To manage your ACH payments electronically, leave this form, visit your Member Portal and click on Recurring Payments.

Participant Information

Participant Full Name*

First Name

Last Name

Employer Name/ Plan Sponsor*

Member ID*

This can be found on your payment coupons

Email*

In case we have questions regarding this ACH Form submission

Recurring Payment Bank Account Information

Bank Name*

Account Type*

Checking Savings

Account Holder Full Name*

First Name

Last Name

Routing Number*

Account Number*

Attach a copy or photo of a voided check for this account

No File Chosen

File uploads may not work on some mobile devices.

Authorization

I authorize Voya Benefits Company, LLC ("Company") to initiate debit entries from my checking or savings account for my recurring scheduled payment via ACH. If the required payment changes for any reason, this authorization will be automatically amended to authorize the debit of the amount equal to the new required premium payment plus any additional service fees, if any. This authorization will remain in full force and effective until Voya Benefits Company, LLC has received written notification of my termination in a time and manner as to afford Voya Benefits Company, LLC reasonable opportunity to act on it. I understand that the automatic debits will automatically cease if my coverage ends, is terminated, or my automatic debit rejects for insufficient funds. I understand and agree to the terms outlined and authorize Voya Benefits Company, LLC to make appropriate changes to my required premium deduction as necessary.

I authorize Voya Benefits Company, LLC ("Company") to terminate debit entries from my checking or savings account for my recurring scheduled payment via ACH. I understand that the automatic debits will cease, and it is my responsibility to make payment via check or alternative payment method to avoid coverage termination.

Account Holder Signature*

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Use your mouse or finger to draw your signature above

Date*