Your Information

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Bank or Financial Institution Information

Click or drag a file to this area to upload.
Please provide a copy of a voided check for checking account or a deposit ticket for a savings account.

Authorization Agreement for Electronic Funds Transfer (EFT):

I hereby authorize Kentucky Employers’ Mutual Insurance (KEMI) to automatically initiate credit entries to my Account, at the Financial Institution named in this application, for payment of Workers’ Compensation benefits. I further authorize the Financial Institution to accept these credit entries and post them to my account. If corrections in the credit amount are necessary it may involve adjustments (credit or debit) to my account. I understand that both the Financial Institution and KEMI reserve the right to terminate my participation in this payment plan. I also understand that I may discontinue enrollment at any time with written notice to KEMI, after allowing KEMI and the bank a reasonable time to act upon my notification.
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