Benefit Design Group

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*Company or Broker Name:
*Tax ID or SS#:
I (we) hereby authorize BENEFIT DESIGN GROUP, LLC, herein after called COMPANY, to initiate credit entries and to initiate, IF NECESSARY, DEBIT AND ADJUSTMENTS FOR ANY CREDIT ENTRIES IN ERROR to my (our) checking savings account (select one) indicated below and the depository named below, hereinafter called DEPOSITORY, to credit and/or debit the same to such account.

*Depository Name:
*Branch:
*City:
* State:	Zip:
*Transit/ABA#:		Account #:
This authority is to remain in full force and effect until COMPANY has received written notification from me (or either of us) of its termination in such time and in such manner as to afford COMPANY a reasonable opportunity to act on it.

*Name(s):
ID Number:
Signature:		*Date:
Please attach a voided check if a checking account is selected.

FOR COMPANY USE ONLY

Date Received:
Processed by:
Submission of this form will allow Benefit Design Group, LLC to process the information contained in this document. The Employer agrees to maintain a signed copy of this document. Benefit Design Group, LLC, reserves the right to request a copy of the signed document at any time from the Employer.



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