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Automatic Payment Plan Form

Please click on the Automatic Payment Plan Form below. Once the form appears on your screen, print the form and follow the instructions provided. If you have any questions regarding the Automatic Payment Plan, please contact your ABE Insurance Plan Specialist at 800-621-8981.

If you are currently enrolled in the ABE automatic payment plan and need to change your bank account information it is NOT necessary to complete a new form. Simply fax a copy of a voided check from the new account to 312-988-6401 or mail a voided check to 321 N. Clark Street, Chicago, IL 60654-7648, with a note as to which insurance plan(s) are affected.

All of these documents have been created using Adobe Acrobat and are saved as Portable Document Format (PDF) files. They can be viewed using Adobe Acrobat Reader. If you do not have the Adobe Acrobat Reader, download and install the reader by pushing the "Get Acrobat" Reader button below.

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