Colonial Life Direct Deposit Request printable pdf download

COLONIAL LIFE DIRECT DEPOSIT REQUEST

THIS FORM CANCELS AND SUPERSEDES

ANY PREVIOUS DIRECT DEPOSIT REQUESTS.

BE SURE TO FILL IT OUT COMPLETELY AND ACCURATELY.

PLEASE PRINT

PRODUCER INFORMATION:

LIST ALL PRODUCER CODE #s.:_______________________________

NAME: _______________________________________________________________

NEW

CHANGE

SSN/EIN NUMBER ______________________________ PERSONAL E-MAIL ___________________________________

*You may deposit your total compensation to one account (checking or savings), or you may split your compensation between three

different accounts (any form of checking and savings). Designate a primary account and percentage. Designate a second and/or third

account and percentage only if you plan to split deposits. This form will be returned if all information is not completed.

PRIMARY ACCOUNT:

Percentage ___________

Name of Financial Institution (Bank)

Routing/Transit Number*

Account Number*

Type of Account

_________________________________

__ __ __ __ __ __ __ __ __

_______________

Checking

Savings

SECONDARY ACCOUNT:

Percentage ___________

Name of Financial Institution (Bank)

Routing/Transit Number*

Account Number*

Type of Account

_________________________________

__ __ __ __ __ __ __ __ __

_______________

Checking

Savings

THIRD ACCOUNT:

Percentage ___________

Name of Financial Institution (Bank)

Routing/Transit Number*

Account Number*

Type of Account

_________________________________

__ __ __ __ __ __ __ __ __

_______________

Checking

Savings

When you have completed this form, attach a voided check and mail it to the address below. Deposit slips or

counter checks are NOT accepted. A change in your banking information will suspend your Direct Deposit

for approximately 2-3 weeks and you will receive a paper check in the interim.

Read and sign the following:

DIRECT DEPOSIT AUTHORIZATION

I hereby authorize Colonial Life & Accident Insurance Company to deposit my earnings (credits) as indicated above. It is understood that

deposit(s) will not begin until after a pre-notification has been completed. Colonial Life & Accident Insurance Company may withdraw any money

(debits) deposited to my account, in error, for such manner as to afford Colonial Life & Accident Insurance Company and my Financial Institution(s) a

reasonable opportunity to act on it. I understand that depositing my earnings into the account(s) above does not affect how income will be reported on

my annual 1099 form. I also understand that Colonial Life & Accident Insurance Company will not be held responsible for any NSF or return check

charges incurred by me. This authorization will remain in effect as long as I remain eligible for participation unless I (we) notify Colonial Life & Accident

Insurance Company, in writing, that the authorization is terminated. I (we) will provide the termination notice at such time and in such a way that

Colonial Life & Accident Insurance Company will have reasonable time to act upon it. Colonial Life & Accident Insurance Company reserves the right

to terminate this Direct Deposit Authorization at their discretion. Should the direct deposit authorization be terminated, a check will be issued for any

commissions due.

________________________________________________

___ ___ / ___ ___ / ___ ___ ___ ___

Signature

Date

NOTE: For all accounts, call your financial

Please Return To:

institution to verify your account and transit

Colonial Life

routing number(s).

P. O. Box 1365

Columbia, SC 29202-1365