Individual Check It Out^®

Enrollment/change form.

Required fields are noted with an asterisk *.

* Reason for submitting form

Subscriber Information
* Subscriber's First Name	Middle Initial	* Last Name
Identification Number (as it appears on the ID card)

Address Information
* Street Address
* City	* State	* ZIP Code
* Is this a new address?

Financial Institution Information
* Account Type

* Name of Financial Institution	* ABA Number	* Confirm ABA Number
* Name on Bank Account	* Bank Account Number	* Confirm Bank Account Number
* Signature of Capital BlueCross Subscriber
Signature if joint account	Signature if account is other than subscriber's	Date

By completing this form, I/we authorize Capital BlueCross and its subsidiaries, Capital Advantage Insurance Company^®, Capital Advantage Assurance Company^®, and Keystone Health Plan^® Central, and the financial institution named above, to deduct the amount of the premiums for my health coverage from my account.

I agree to maintain sufficient funds in the account to permit these deductions. If the account does not have sufficient funds at the time of transfer, I understand that my Capital BlueCross health care coverage may be cancelled.

By typing my full name below and submitting this form, I understand that I am creating an "Electronic Signature" that carries the same legal obligations of a written signature.

* Authorized Signature (acts as electronic signature)

* Date Submitted

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Individual Check It Out®

Enrollment/change form.

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Individual Check It Out^®