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Electronic Fund Transfer Enrollment Form. This is a Missouri form and can be use in Workers Comp.
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Tags: Electronic Fund Transfer Enrollment Form, WC-132, Missouri Workers Comp,
MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS
DIVISION OF WORKERS’ COMPENSATION
ELECTRONIC FUND TRANSFER ENROLLMENT FORM
(For ACH only)
This form must be used by the Workers’ Compensation Insurance Carriers, the Self-Insured Employers and the Self-Insured
Groups or trusts who would like to make Second Injury Fund surcharge payments beginning in CY 2003 to the Missouri
Division of Workers’ Compensation (Division) through an Electronic Fund Transfer. Under the Missouri workers’
compensation law, Chapter 287 RSMo, the surcharge payments are deposited to the credit of the Second Injury Fund.
Recipients of this form should bring this information to the attention of their respective financial institution.
The funds transfer is governed by the Electronic Fund Transfer Act of 1978 (Title XX, Public Law 95-630, 92 Stat. 3728, 15
U.S.C. Section 1693, et. seq.) as amended from time to time and Article 4A of the Uniform Commercial Code – Funds Transfer.
COMMERCIAL INSURANCE COMPANY INFORMATION
NAME
ADDRESS
NAIC NO.
FEIN NO.
CONTACT PERSON NAME
TITLE
E-MAIL ADDRESS
TELEPHONE NO.
EXEC. OFFICER PRINTED NAME
TITLE
SIGNATURE
DATE
SELF INSURED EMPLOYER/GROUP/TRUST INFORMATION
NAME
ADDRESS
NAIC NO.
FEIN NO.
CONTACT PERSON NAME
TITLE
E-MAIL ADDRESS
TELEPHONE NO.
EXEC. OFFICER PRINTED NAME
TITLE
SIGNATURE
DATE
DIVISION OF WORKERS’ COMPENSATION BANK INFORMATION
NAME
State of Missouri (Processing through Central Trust Bank)
ROUTING NUMBER
086507174
ACCOUNT NUMBER
6250081
This enrollment form may be amended only by submitting a new enrollment form reflecting the amendment to the Division, at
least thirty (30) days prior to the effective date of the amendment.
By signing this enrollment form, the executive officer of the Commercial Insurance Company, Self-Insured Employer or
Group/Trust warrants under penalty of perjury, that he/she has the necessary power and authority to complete this form and is
duly authorized to do so.
If there has been a name or ownership change in the past 12 months, please indicate the previous name(s) or owner(s).
WC-132 (08-07) AI
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