Agent or Agency requesting Automatic Deposit:
FIN / SS:
Phone:
Please indicate type of account: -Please Select-Set UpChangeCancel
Business Account: -Please Select-YesNo
Personal Account: -Please Select-YesNo
Bank Name:
Bank City
Bank State:
Bank Zip:
Bank Phone:
Bank Routing Number:
Bank Account Number:
This authorization will remain in force until written notification of termination or change is received by Sure Card Benefits in such time and in such manner as to afford Sure Card Benefits a reasonable opportunity to act on it. NOTE: Direct deposit set-up requires that the bank account and routing number must be verified for accuracy before any funds are transferred. For this reason, you may receive one or two commission checks that need to be cashed. Plus, transferred funds may be delayed by your bank.
Electronic Signature:
Date
