Agency Internal Setuplease provide the informationbelow o initiatetheK - PDF document

Agency Internal Setuplease provide the i
Agency Internal Setuplease provide the informationbelow o initiatetheKEMI setup process for your agency. Agency InformationAgency Name________________________________________________________________________Agency Federal Identification Number(FEIN)_______________________________________________Physical AddressPhone (___________________________________ Fax (KEMI.com Agency Administrator Designationto designate someoneotheron howo complete theirNameof Designee ____________________________________________________________________Email Address________________________________________________________________________also mail the uthorized Signature ____________________________________________ Date __________________gency Commission Setup for Direct Deposit of Agency CommissionAction: Enroll ChangeType of Account: Checking Savings OtherName as it Appears on Bank Account _____________________________________________________Name of Banking or Financial Institution ___________________________________________________ABA or Bank Routing Number______________________ Account Number_______________________City / State / Zip of Banking or Financial Institution ___________________________________________ Phone for Banking or Financial Institution (___________________________________How would you like to be notified when a deposit is processed? Email MailEmail Address (if different from the Primary Contact email address on the first page)___________________________________________________________________IMPORTANT: Enclose a voided check, deposit slip or other bank document with this completed form. Your request cannot be processed without this information.Authorized Agreement for Direct Deposit via Electronic Funds Transfer (EFT)By signing below, hereby authorize Kentucky Employers' Mutual Insurance (KEMI) to automatically initiate credit entries tomy account at the financial institution named above. I further authorize the financial institution to accept these credit entries and post them to my account. I understand that if corrections in the credit amount are necessary it may involve adjustments (credit or debit) to my account, and I hereby authorize such corrections. I understand that both the financial institution and KEMI reserve the right to terminate my participation in this direct deposit program. I also understand that I may discontinue enrollment at any time with written notice to KEMI, after allowing KEMI and the financial institution a reasonable amount of time to act upon my notification.Printed Name _____________________________________ Title _______________________________Authorized Signature __________________________________________Date ____________________It is the responsibility of the agency to notify KEMI of any changes relating to the information on this form.You may also mail the form to 250 West Main Street, Suite 900 ATTN: KEMI Agency Setup, Lexington, KY 40507-1724.Agency Internal Setuplease provide the informationbelow o initiatetheKEMI setup process for your agency. Agency InformationAgency Name________________________________________________________________________Agency Federal Identification Number(FEIN)_______________________________________________Physical Address_____________________________________________________________________City_____________________________________________ State ____________ Zip _____________Mailing Address (if different from above)___________________________________________________City_____________________________________________ State ____________ Zip _____________Phone (___________________________________ Fax (________)_____________________________ to designate someone otheron howo complete theirNameof Designee ____________________________________________________________________Email Address________________________________________________________________________also mail the Agentontactame_________________________________________________________________Emailddress________________________________________________________________________KentuckyOIicense Number__________________________________________________________uthorized Signature ____________________________________________ Dat__________________KEMI.comgencydministratorDesignationKEMI does not appoint agents. Agents licensed in the state of Kentucky can do business with KEMI but Kresponsible for ceating and maintaining the security of all existing and new authorized user name(s) and password(s). In addition, the designated administrator shall have the rights to grant and revoke authority for the Account Holder up to, but not exceeding, the administrator's own rights.Registered users with the “Agent” role may create a Quick Quote, su

bmit an online application, make payment
bmit an online application, make payments electronically (via check or with Visa, Mastercard or Discover), view their book of business with KEMI, setup email alerts, and more. The Account Holder and all authorized users of the Account Holder are bound by the terms and conditions set forth in the Terms and Conditions of Use Agreement. gency Commission Setup for Direct Deposit of Agency CommissionAction: Enroll ChangeType of Account: Checking Savings OtherName as it Appears on Bank Account _____________________________________________________Name of Banking or Financial Institution ___________________________________________________ABA or Bank Routing Number______________________ Account Number_______________________City / State / Zip of Banking or Financial Institution ___________________________________________ Phone for Banking or Financial Institution (___________________________________How would you like to be notified when a deposit is processed? Email MailEmail Address (if different from the Primary Contact email address on the first page)___________________________________________________________________IMPORTANT: Enclose a voided check, deposit slip or other bank document with this completed form. Your request cannot be processed without this information.Authorized Agreement for Direct Deposit via Electronic Funds Transfer (EFT)By signing below, hereby authorize Kentucky Employers' Mutual Insurance (KEMI) to automatically initiate credit entries tomy account at the financial institution named above. I further authorize the financial institution to accept these credit entries and post them to my account. I understand that if corrections in the credit amount are necessary it may involve adjustments (credit or debit) to my account, and I hereby authorize such corrections. I understand that both the financial institution and KEMI reserve the right to terminate my participation in this direct deposit program. I also understand that I may discontinue enrollment at any time with written notice to KEMI, after allowing KEMI and the financial institution a reasonable amount of time to act upon my notification.Printed Name _____________________________________ Title _______________________________Authorized Signature __________________________________________Date ____________________It is the responsibility of the agency to notify KEMI of any changes relating to the information on this form.Please send this completed form as an attachment toYou may also mail the form to 250 West Main Street, Suite 900 ATTN: KEMI Agency Setup, Lexington, KY 40507-1724.Agency Internal Setuplease provide the informationbelow o initiatetheKEMI setup process for your agency. Agency InformationAgency Name________________________________________________________________________Agency Federal Identification Number(FEIN)_______________________________________________Physical Address_____________________________________________________________________City_____________________________________________ State ____________ Zip _____________Mailing Address (if different from above)___________________________________________________City_____________________________________________ State ____________ Zip _____________Phone (___________________________________ Fax (________)_____________________________ to designate someone otheron howo complete theirNameof Designee ____________________________________________________________________Email Address________________________________________________________________________as an attachment also mail the Agentontactame_________________________________________________________________Emailddress________________________________________________________________________KentuckyOIicense Number__________________________________________________________uthorized Signature ____________________________________________ Dat__________________KEMI.comgencydministratorDesignationKEMI does not appoint agents. Agents licensed in the state of Kentucky can do business with KEMI but Kount Holder's administrator is ceating and maintaining the security of all existing and new authorized user name(s) and n addition, the designated administrator shall have the rights to grant and revoke authority for the Account Holder up to, but not exceeding, the administrator's own rights.ers with the “Agent” role may create a Quick Quote, submit an online application, make payments electronically (via check or with Visa, Mastercard or Discover), view their book of business with etup email alerts, and more. The Account Holder and all authorized users of the Account Holder are bound by the terms and conditions set forth in the Terms and Conditions ofe Agreement.