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Employee/Insured/Member Signature

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I hereby authorize the Company to initiate deposit to checking OR savings account as indicated above and the depository named above to credit same to such account and that is the payment of the claim. This authority is to remain in full force and effect until the Company has received written notification from me of its termination/change in such manner as to afford the Company a reasonable opportunity to act on it.<br/><br/> <strong>Notice Regarding Electronic Funds Transfer:</strong> When you select electronic funds transfer as your payment method, we may receive and contribute customer account and payment account data to a third party consumer reporting agency to confirm the feasibility of a transaction to your account.<br/><br/> <i>For your protection, if your claim is approved and we are unable to validate your banking information, we will issue you a check to avoid any delay in payment.</i><br/><br/> By typing your name in the box below, you are electronically signing this document. Your electronic signature will be legally binding and enforceable and the legal equivalent of your handwritten signature.