ASRS Long Term Disability
Direct Deposit Authorization Form
PART 1: To be Completed by Employee
Employer: |
ARIZONA STATE RETIREMENT SYSTEM |
Employee: |
First Name _____________________Middle Initial_______ Last Name___________________________ |
SSN: |
______________________________ |
Agreement
I authorize Sedgwick and my Employer, at their discretion, to deposit my approved disability benefit payments into my account as indicated below.
This authorization will remain in effect until I give written notice to Sedgwick either to change or cancel this authorization, in such time and in such manner as to afford Sedgwick a reasonable opportunity to act on it. I understand that my deposit will not be posted to my account until the date of my monthly benefit payment.
I have provided Sedgwick with my financial institution information solely for the purpose of verifying my account number and transit/routing information.
I grant Sedgwick and my Employer the right to correct any Electronic Funds Transfer resulting from erroneous overpayment by debiting my accounts to the extent of such overpayment. I further understand that Sedgwick or my Employer is not responsible for any costs or service charges incurred by me as a result of Sedgwick’s actions related to Electronic Funds Transfer.
Action Requested
Please establish a NEW direct deposit to the bank and account listed below.
Please CHANGE my direct deposit, and direct my benefit payments to the bank and account listed below.
Please CANCEL the direct deposit of my benefit payments to the bank and account listed below and send my benefit payment check to me in the mail.
Employee SignatureDate
PART 2: Financial Institution Information
Name of Financial Institution:
Routing #: |
|
|
|
|
|
|
|
|
|
|
|
|
Telephone #: ( |
|
|
|
) |
|
|
|
- |
|
|
|
|
Account #: |
|
|
|
|
|
|
|
|
|
|
|
|
Type of Account: |
|
|
Checking |
|
Savings |
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
After completing this form, please fax it to Sedgwick at (855) 800-5116 or mail it to Sedgwick, PO Box 14648, Lexington, KY 40512. Sedgwick only needs one copy of this form, so please choose one method of delivery only.
For Sedgwick Use Only
Prenote Completed By: ___________________________________________________ Date: ________________________