BeniComp Electronic Funds Transfer (Direct Deposit) Agreement

Group Name

This is your Company's Name
Group Number

The group number is the number assigned to your group and can be found on the first page of your Certificate. If you do not know your group number, please ask your company representative or click here.
Insured's Name Insured's Name First Last
Insured's Last 4 Digits of SS#
Maximum of 4 digits allowed. Currently Entered: 0 digits.
Email Address for EOB Notifications
Home Phone Number Home Phone Number - ### - ### ####
Daytime Phone Number Daytime Phone Number - ### - ### ####
Please Select One:

Please Select One: New Enrollment Account Change Cancel Electronic Funds Transfer
Change Effective Date Change Effective Date / MM / DD YYYY
Cancel Effective Date Cancel Effective Date / MM / DD YYYY
Bank Name
Account Type
Routing/ABA Number
Maximum of 9 characters allowed. Currently Entered: 0 characters.
Account Number
Please attach a voided check (for checking account deposits). For savings account deposits, a routing number and account number need to be obtained from the bank.

Attach Files
Employee Authorization

I authorize BeniComp and its financial institution to initiate credit electronically or otherwise to my checking or savings account. This authorization will remain in effect until BeniComp has received written notification.
Insured's Signature

Draw or Type

I understand this is a legal representation of my signature. Clear

Full Name

I understand this is a legal representation of my signature.
Signed Date Signed Date / MM / DD YYYY
Administered by BeniComp, Inc.
8310 Clinton Park Drive
Fort Wayne, IN 46825
Phone (866) 797-3343

The promoters of this product make no representation concerning the tax advantages of this program and recommend that policyholders consult their tax advisor.

BeniComp Electronic Funds Transfer (Direct Deposit) Agreement

BeniComp Electronic Funds Transfer (Direct Deposit) Agreement

Employee Authorization