Authorization Agreement for Direct Withdrawals (ACH Debits)

Reimburse your executives quickly when you sign up for ACH below.

NOTE: The ACH Debit Form below is for employers who will be funding the claims. If you are an executive who would like to be reimbursed electronically then please click here to fill out the employee EFT form.

Company Name *
Federal ID Number *
I (We) hereby authorize Benicomp, Inc. to initiate debit entries from my (our) Checking or Savings (select one below) account indicated below at the depository financial institution named below, hereinafter called DEPOSITORY, and to credit the same to such account.
Type of account *

Type of account Checking Savings
Depository Name *
Branch *
City *
State *
Zipcode *
Routing Number *
Must be 9 digits. Currently Entered: 0 digits.
Account Number *
Maximum of 17 allowed. Currently Entered: 0 .
Account Number
Maximum of 17 digits allowed. Currently Entered: 0 digits.
Verify Account Number *
Maximum of 17 digits allowed. Currently Entered: 0 digits.
This authorization is to remain in full force and effect until Benicomp, Inc. has received written notification from me (or either of us) of its termination in such time and in such manner as to afford Benicomp, Inc. and DEPOSITORY a reasonable opportunity to act on it.
Please apply ACH funding to all invoices after the following effective date: Please apply ACH funding to all invoices after the following effective date: * / MM / DD YYYY
Person 1
Name Name * First Last
Title *
Draw your signature into the box below. *

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.
Date Date * / MM / DD YYYY
Person 2
Name Name First Last
Title
Date Date / MM / DD YYYY
Draw your signature into the box below.

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.
NOTE:

NOTE: All written debit authorizations must provide that the receiver may revoke the authorization only by notifying the originator in the manner specified in the authorization. Authorizing the transfer of funds does not guarantee coverage; the application and base medical plan must meet underwriting requirements prior to our issuing the policy.
PLEASE ATTACH A COPY OF A VOIDED CHECK *

Attach Files
Notes Section:

If you would like to use your ACH profile to pull funds for outstanding invoices, please indicate which invoices you would like to be pulled. Thank you!

Authorization Agreement for Direct Withdrawals (ACH Debits)

Authorization Agreement for Direct Withdrawals (ACH Debits)

Person 1

Person 2

NOTE: