CompSource Oklahoma EFT Authorization Form

FORM 8473

CompSource Oklahoma

Electronic Fund Transfer Authorization

Policy Class (POL)

Name of Policyholder: ______________________________________________________
CompSource Oklahoma Policyholder Account Number (first eight digits): _____________
Policyholder Address: _______________________________________________________
	_______________________________________________________
City:	_______________________________________________________
State:	______________________________	Zip:	___________________
Policyholder Phone Number (include area code): __________________________________
I hereby authorize 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 CompSource Oklahoma has received written notification from the policyholder of its termination in such time and in such manner as to afford CompSource Oklahoma and the policyholder’s financial institution a reasonable opportunity to act on it.
__________________________________________________ Policyholder Signature		Date:	______/______/______

Attach a VOIDED check or a letter of verification from your
financial institution. DEPOSIT SLIPS are not acceptable.

Please mail this completed form to:
	CompSource Oklahoma
	EFT Processing
	PO Box 53505
	Oklahoma City OK 73152-3505