Your Information

Name *

Claim Number *

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Phone Number

If you would like to be notified of payment by email, please provide your email address:

Email

Bank or Financial Institution Information

Name of Bank or Financial Institution *

Address of Bank or Financial Institution *

Address Line 1

Address Line 2

City

State

Zip Code

Bank or Financial Institution Phone Number

Bank Routing Number *

Checking or Savings Account Number *

Supporting Documentation

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.

Signature

Clear Signature

Direct Deposit Form

Your Information

Bank or Financial Institution Information

Authorization Agreement for Electronic Funds Transfer (EFT):

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