Enrollment by Monthly Check Service/Auto Debit

1. Complete the attached Enrollment Form.
2. Complete the attached Monthly Request for Preauthorized Check/Debit Form.
3. Mail the completed forms and a voided check from the designated account.

Your coverage will begin on the first day of the month following receipt of payment and Enrollment Form.

Mail to:
Mass Benefits
PO Box 828
Annandale, VA 22003-0828