Secure form

Set up your premium payments

Your Medicare Supplement company needs your bank information to draft your monthly premium. Instead of reading it over the phone, you can enter it here.

Your information is sent over an encrypted connection and stored encrypted.
We never send your bank numbers by email.
Only your licensed agent can view them.

What you'll need: a check or a bank statement. Your routing number is the 9 digits at the bottom left of a check. Your account number comes after it.

About you

First name *

Last name *

Phone *

Email (optional)

ZIP code *

Date of birth (optional)

Helps us match your file.

Insurance company you're applying with (optional)

Your bank

Bank or financial institution (including branch, if any) *

Routing number *

9 digits

Account number *

4 to 17 digits

Verify account number *

Bank address (optional)

Bank city (optional)

Bank state (optional)

Bank ZIP code (optional)

Account type *

CheckingSavings

Are you authorized to use this account? *

YesNo

Bill day *

The day of the month your premium is drafted. Many people pick a day just after their Social Security or pension payment arrives.

Account name (as it appears on the account) *

I'm giving First American Medicare my bank information so my licensed agent can add it to my Medicare Supplement application for my premium payments. The insurance company, not First American Medicare, will draft my payments. *

Type your full name as your signature *