Eft Enrollment Form - Idaho Department Of Insurance - 2015

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State of Idaho
DEPARTMENT OF INSURANCE
C.L. “BUTCH” OTTER
700 West State Street, 3rd Floor
DEAN L. CAMERON
Governor
Director
P.O. Box 83720
Boise, Idaho 83720-0043
Phone (208)334-4250
FAX # (208)334-4398
EFT Enrollment Form – Please print or type.
Department of
Please retain a copy of this form for your records. Return the completed form to the Idaho
Insurance. Attn: Melissa Sargent-Smith – Premium Tax Section
NEW ENROLLMENT
OR
MODIFY ORIGINAL ENROLLMENT
EFT Tax Payment Type: Department of Insurance
(Tax Type 07170)
Indicate which method you will use in sending your payment.
Automated Clearing House (ACH) Credit
Wire Transfer
Federal Tax ID No. (9): __ __ __ __ __ __ __ __ __
Company Name (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Contact (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
Address (25): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ __
City (15): __ __ __ __ __ __ __ __ __ __ __ __ __ __ __ State (2): __ __
Zip: __ __ __ __ __ - __ __ __ __ Telephone: (__ __ __) __ __ __ - __ __ __ __
Date: __ __ - __ __ - __ __ __ __
INS-PTX-EFT enrollment (10-15)

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