AUTHORIZATION FOR ELECTRONIC FUNDS TRANSFER (DISABILITY INCOME INSURANCE)

The forms provided here are standard Administration forms. See the other links on the sidebar for Claim Forms. Any Enrollment forms and Evidence of Insurability forms must be obtained through your local Account Representative.

Authorization for Electronic Funds Transfer (Disability Income Insurance)

• Not all plans have this option: contact your Disability Benefit Specialist for more information.
• Distribute this form to disabled employees who want to set up direct deposit for payment of their Disability Income benefits.