Fillable For Direct Deposit Of Claims Payment (Aflac Insurance)

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For Direct Deposit Of Claims Payment (Aflac Insurance)

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The For Direct Deposit Of Claims Payment (Aflac Insurance) form is 1 page long and contains:

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  • 5 check-boxes
  • 16 other fields

Country of origin: US
File type: PDF

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EFT Form 2016
Electronic Funds Transaction Authorization
Send to: Continental American Insurance Company
Post Office Box 84075
Columbus, Georgia 31993
Phone: (800) 433-3036 Fax (866) 849-2970
Email: groupclaimfiling@aflac.com
Authorization Agreement for Direct Deposit
I would like to: Start Stop Change direct deposit of my claim payment(s).
Account Type:
Checking Savings
**** Please provide a blank voided check or
direct deposit form from your financial
institution. Incomplete or inaccurate
information will not be processed.
9-Digit Routing Number:
Account Number:
Name of Financial Institution:
Address:
City:
State:
Zip:
Phone:
I authorize Continental American Insurance Company (CAIC) to initiate credit entries, and, if errors occur, I
authorize the correction of entries to my account as indicated. This authorization remains effective and in full force
until CAIC receives written notification from me of its termination in such time and in such manner to afford CAIC a
reasonable opportunity to act on it. Please notify CAIC immediately if your financial institution information has
changed by sending notification to the address indicated above. Should you have any questions, please contact us at
1-800-433-3036.
Policy/Certificate Holder’s Name (Print):
Date of Birth:
Address:
City/State/Zip:
Phone #:
E-mail Address:
Employer Name or Group #:
Certificate #:
***By providing your e-mail address above, you consent to the use of electronic transactions in connection with your CAIC policies, contracts, and/or
accounts to the extent available and permitted by law (which may include, but not limited to: invoices, claim correspondence, contracts, surveys, and
other materials that CAIC is, or may be, legally required to deliver to you)
Note: Forms received without signature will not be processed. Electronic signatures not accepted.
Policy/Certificate Holder Signature (Required ) Date Signed:
Continental American Insurance Company (CAIC), a proud member of the Aflac family of insurers, is a wholly-owned subsidiary of Aflac Incorporated and underwrites group coverage. Aflac is
not licensed to solicit business in New York, Guam, Puerto Rico, or the Virgin Islands. For groups sitused in California, coverage is underwritten by Continental American Life Insurance
Company. For groups sitused in New York, coverage is underwritten by American Family Life Assurance Company of New York.
Continental American Insurance Company • 1600 Williams St • Columbia, South Carolina 29201 • 1-800-433-3036 toll-free • 1-866-849-2970 fax
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For Direct Deposit Of Claims Payment (Aflac Insurance)

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Completed 19 July 2020

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