ACH Authorization

Personal Information

Please provide your contact and identification details.

First Name

Last Name

Insurance Group Identifier

Employee Union ID Number

Phone Number

Email Address

Bank Account Information

I certify that I am an authorized signer or account holder for the bank account listed below and that the information I provide is accurate.

Financial Institution Name

ABA Routing Number

ℹ Your 9-digit routing number is printed on the bottom-left of your checks. Routing numbers are verified against the Federal Reserve database.

Account Number

Confirm Account Number

Account Type

Checking Savings

Name on Account

Authorization & Acknowledgment

Please review the authorization terms below before signing.

Authorization Purpose

This authorization is for the collection of premium payments associated with the Aflac benefits I have elected through my employer, union, or related benefit program.

Authorized Debit Amounts

I authorize Platypus Payroll to debit my account for the amount necessary to pay my Aflac premium obligations as they become due, including recurring premium payments and any approved adjustments necessary to correct prior underpayments or over-payments, as permitted by law and applicable plan rules.

Timing of Debits

I understand that debits may occur on a recurring basis according to the premium payment schedule established for my coverage, payroll cycle, billing cycle, or other applicable schedule communicated to me.

Account Information

I certify that I am an authorized signer or account holder for the bank account listed below and that the information I provide is accurate.

Insufficient Funds / Failed Transactions

If any authorized debit is returned unpaid, rejected, or otherwise not successfully processed for any reason, including but not limited to insufficient funds, a closed account, invalid account information, or a stop payment order, I understand and agree that the applicable premium amount shall remain due and owing. I authorize Platypus Payroll LLC to reinitiate the debit as permitted by applicable law and NACHA rules, or to contact me to arrange an alternative method of payment. I further understand and agree that any returned, rejected, or failed transaction may result in the assessment of a $5.00 failed transaction fee. I acknowledge that repeated failed transactions or nonpayment of required premiums may result in delayed, lapsed, or terminated coverage, subject to the terms of the applicable benefit plan or policy.

Changes to Authorization

This authorization will remain in effect until:

my Aflac Benefits coverage ends,
premium payments are no longer required,
I revoke this authorization in writing, or
Platypus Payroll terminates this payment method.

Revocation of Authorization

I may revoke this authorization at any time by providing written notice to Platypus Payroll at least 10 business days before the next scheduled debit. I understand that revoking this authorization does not cancel my insurance coverage or eliminate any amounts I owe for premiums already due.

Corrections and Adjustments

I authorize Platypus Payroll to make correcting entries, including credit entries, if an erroneous debit is made to my account, in accordance with applicable ACH rules.

No Change to Coverage Terms

I understand that this authorization relates only to payment of premiums and does not alter the terms, conditions, or eligibility requirements of my Aflac coverage.

I have read and understand this authorization and voluntarily agree to its terms.

Electronic Signature ✍ By typing your name, you agree this constitutes your legal electronic signature.

Date

Authorization Submitted Successfully

Thank you. Your ACH Authorization has been received and recorded. You may close this window and return to Employee Navigator to complete your benefits enrollment.

Confirmation ID:

Submission Failed

We were unable to process your submission. Please try again, or contact Platypus Payroll for assistance.