FORM 8473
Policy Class (POL)
| Name of Policyholder: ______________________________________________________ | |||
CompSource Oklahoma Policyholder Account Number (first eight digits): _____________ |
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Policyholder Address: _______________________________________________________ |
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_______________________________________________________ |
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City: |
_______________________________________________________ | ||
State: |
______________________________ | Zip: | ___________________ |
Policyholder Phone Number (include area code): __________________________________ |
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| I hereby authorize the Office of the State Treasurer, as agent for CompSource Oklahoma, to initiate debit entries due CompSource Oklahoma, from the checking account indicated on the attached financial document. This authority is to remain in full force and effect until the Office of the State Treasurer has received written notification from the policyholder, or CompSource Oklahoma, of its termination in such time and in such manner as to afford the Office of the State Treasurer and the policyholder’s financial institution a reasonable opportunity to act on it. |
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__________________________________________________ Policyholder Signature |
Date: |
______/______/______ |
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Attach a VOIDED check or
a letter of verification from your
financial institution. DEPOSIT SLIPS are not acceptable.
| Please mail this completed form to: | |
Attn: EFT DEPARTMENT |
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| OFFICE OF THE STATE TREASURER | |
| 217 STATE CAPITOL BUILDING | |
| OKLAHOMA CITY, OK 73105 | |