Client Resources · Billing
Policy & Billing
Information Forms
Download the form you need, complete it, and email it directly to the policyholder service team with your policy number. We keep the process simple.
Available Forms
Select the form you need.
Both forms are available to download, complete offline, and email to the service team. If you need help identifying which form applies to your situation, call us — we’re happy to point you in the right direction.
Employer Bank Draft Authorization
Use this form to authorize automatic bank draft payments for your employer-sponsored policy. Required for setting up new automated billing from your business account.
Bank Draft / Authorization Change
Use this form to update or change existing bank draft authorization — including account changes, routing number updates, or modifications to your current automatic payment setup.
How to Submit
Download the form
Click the download button on the form you need. Open the PDF on your computer or print it out.
Complete all fields
Fill in all required fields carefully. Missing information can delay processing. Sign where indicated.
Email with your policy number
Attach the completed form and send to the policyholder service email below. Always include your policy number.
Allow processing time
Changes typically take 3–5 business days to process. Contact us if you don’t receive confirmation within that window.
Send Completed Forms To
Policyholder Service Email
[email protected]Always include your Policy Number in the subject line or email body.
Need Help?
Not sure which form to use?
Our team is happy to help you identify the right form, confirm your policy number, or answer any questions about the billing process. This is part of the service we provide — just reach out.
Other Resources
Looking for claim forms or other policyholder resources?
Fredrick Insurance Brokers is an independent licensed insurance agency. Billing forms are processed by the respective carrier’s policyholder service team. Processing times may vary. For questions about your specific policy or carrier, contact us directly at (972) 375-0507.
Independent, family-owned health insurance agency serving Denton, TX and all of North Texas. Katherine Clark & John Fredrick work in the best interest of their clients, not the carriers.
📍502 W Oak St STE 102A, Denton, TX 76201
📞(972) 375-0507
⏰Monday – Friday · 9:00 AM – 5:00 PM
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