Employer COBRA ACH Payment Form

Sign up for ACH COBRA Payments

With the electronic payment option it can help reduce the headaches of having to mail COBRA checks each month! Simply complete the below information and OCA will set up your account so that COBRA payments can be directly deposited into your employer bank account!
Company Name *
Your Name *

First Name Last Name
Your E-mail *
Bank Name *
Bank Account Number *
Bank Routing Number (9 digits) *
If available, please upload a voided check here:

Browse Files

Cancel of
Here's a sample voided check
Employer Direct Deposit Authorization

By signing this agreement, I authorize OCA to remit the COBRA monthly premiums via EFT to the employer bank account listed below. Premiums are remitted twice a month (if applicable).
Authorized Employer Signature *
Should be Empty:

Sign up for ACH COBRA Payments