Electronic Transfer for Payment

New Group: Return this form and your Employer Application to your Kare KONEC Account Executive.

Existing Group: You can make future payments by logging into your account online at www.karekonecmedical.com, or email this form to accounts @karekonnecmedical.com. If you need further assistance, call us at: 876-715-4593.

Note: Kare KONEC also accepts credit card payments for group coverage.

I authorize Kare KONEC to withdraw the amount due, based on the final enrollment, from the account below:

One-time withdrawal for the first month’s payment based on Your Total Premium. This account information will be securely saved for the convenience of making future payments. You may make changes to this information by logging into your account online at KarekonecMedical.com. If you need further assistance, call us at: 876-715-4593.

Check the box only if you would like recurring payments . Future autopay/recurring payment*

Withdraw statement balance 4 days before the due date (other options are available at KarekonecMedical.com once your account is set up).

*If selecting autopay, the first payment will be based on the first billing statement, which can be as much as 2 months, due to billing cycles. If this payment is returned unpaid, I authorize Kare KONEC to resubmit the payment and charge this account an additional insufficient funds fee for the maximum amount allowed by the state as a result of a returned check.

I affirm that I have the authority to contract with Kare KONEC and its affiliates on behalf of the group.