MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS 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. CONTACT PERSON NAME E-MAIL ADDRESS EXEC. OFFICER PRINTED NAME SIGNATURE TITLE DATE TITLE TELEPHONE NO. FEIN NO. SELF INSURED EMPLOYER/GROUP/TRUST INFORMATION NAME ADDRESS NAIC NO. CONTACT PERSON NAME E-MAIL ADDRESS EXEC. OFFICER PRINTED NAME SIGNATURE TITLE DATE TITLE TELEPHONE NO. FEIN NO. DIVISION OF WORKERS' COMPENSATION BANK INFORMATION NAME ROUTING NUMBER ACCOUNT NUMBER State of Missouri (Processing through Central Trust Bank) 086507174 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 (04-12) AI American LegalNet, Inc. www.FormsWorkFlow.com