Initial Payment for Covered California Plan

Primary Covered Ca Account Holder Name

First Name *

Last Name *

Card Information

Card Number *

Card Type *

Expiration Date *

Security Code (CVV) *

Cardholder First Name *

Cardholder Last Name *

Billing Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Payment Detail

Expected 1st Month Premium * 🛈

Would you like to use the same information for subsequent payments? * 🛈

Authorization for Payment

Payment Authorization

I request and authorize my chosen carrier to initiate a credit/debit card transaction for the monthly payment due. The initial monthly payment will be processed at the completion of eligibility review. If I have selected the automatic monthly payment option above, I also authorize automatic monthly payments to be made. I understand that my monthly payment may vary as a result of change(s) I make once enrolled, such as, but not limited to, adding and deleting dependents, moving my residence, changing coverage and/or changes made by the carrier of which I am notified according to my plan/policy. This authority is to remain in effect until revoked by me by providing my carrier a 30-day written notice. I understand that should any credit/debit card transaction not be honored, I will automatically be removed from automatic monthly payments and will be billed by mail. I understand I may incur a service charge for any credit/debit card transaction not honored. Please print a copy of this authorization for your records.

An emailed confirmation will be sent to the email on file.