Direct Deposit Enrollment

Direct Deposit Enrollment
Enter your details to set up direct deposit and confirm your banking information.
Authorization Agreement

I hereby authorize My Health IG to initiate automatic deposit to my account at the financial institution named below. I agree not to hold My Health IG responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or by my financial institutions or due to an error on the part of my financial institution in depositing funds to my account. This agreement will remain in effect until Swan Insurance receives a written notice of cancellation from me or my financial institution, or until I submit a new direct deposit form to the Accounting Department.
Full Name
Employer Name
Bank Name
Bank Account Information
Bank Routing Information
Account Type
Signature
Date
MonthDayYear
Date
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