Direct Deposit Authorization
New Change Cancel
Carrier / Agency / Broker Information
Bank Information
This authorization request: From which program do you earn commission payments?
Name
Federal Tax ID # / Social Security #
Phone # (XXX) XXX-XXXX E-Mail Address
Bank Account Type:
Checking Savings
separate form is required
for each
bank account
Bank Name
Bank Phone # (XXX) XXX-XXXX
Your Account # Bank Routing #
Branch Address Suite
City State
ZIP Code
Please attach a voided check for checking accounts
or a voided deposit slip for savings accounts
I hereby authorize CHOICE Administrators
®
to initiate credit
entries for deposit of net commission payments and if
necessary, to initiate debit entries/adjustments for any credits
made in error to my account at the above named Depository
Institution.
This authorization will remain in effect until CHOICE
Administrators has received written notification to terminate or a
new account/financial institution has been designated.
When completed, please return to:
Finance Customer Service
CHOICE Administrators
721 South Parker, Suite 200
Orange, CA 92868
Phone: (714) 567-4390
E-Mail: commissions@calchoice.com
Fax: (714) 972-7368
www.choiceadmin.com
Broker #
Date (MM/DD/YYYY)
CHOICE
Administrators Staff Use
(1 of 1) CA 5218 11/2015
Where to locate your bank account information:
Print Name Date (MM/DD/YYYY)
Signature
California Choice Builder Both
Choice
®®
6877
