EFT Authorization Agreement for Invoice Payments (CDI-177)

Electronic Funds Transfer (EFT) Authorization Agreement for Invoice Payments
STATE OF CALIFORNIA - DEPARTMENT OF INSURANCE
ACCOUNTING SERVICES BUREAU
ACCOUNTS RECEIVABLE SECTION
CDI-177 (REV: 05/2019)

Important Information

EFT Start Date for New Accounts

You will be notified in writing when your agreement is approved. Your confirmation form will indicate when you may start making EFT payments. Do not attempt to pay by EFT before your approved start date. Until your enrollment is confirmed, please continue to submit timely payments in check form to the address provided on your invoice. All due dates and late charges will be enforced.

Payment Method

ACH Debit is the only payment method available for departmental invoices.

Banking Information

You will enter banking information at the time you create your user profile. CDI will not have access to enter or maintain your banking information.

Withdrawal Information

The EFT invoice payment method is optional. By completing the Authorization Agreement form you are voluntarily participating in the EFT program. If you wish to withdraw from this EFT program, you must submit your request in writing to arbilling@insurance.ca.gov. Please note the Department will need at least two weeks prior notice in order to cancel this authorization agreement.

To look up company information, click here.

 

Please check appropriate box:

Section I - Company Information

Enter all company information in this section. Company name and company ID number should match the name and number on your invoices. If you will be making payment for multiple companies, a separate agreement form will be required for each. If your organization has been assigned a National Association of Insurance Commissioners (NAIC) number, please provide this number as well.

Section II - EFT Contact Person

Enter the name and contact information for the person designated to create a user profile and initiate EFT ACH Debit payments to CDI.

Section III - ACH Debit Payment Method

Enter the name and contact information of the representative approving the use of ACH Debit Electronic Funds Transfer as a method of payment for your organization.

I understand that once this authorization agreement is approved by the California Department of Insurance (CDI), I will be provided a temporary security code and a company identification number. I am then required to go to First Data's payment website at www.govone.com/PAYCAL to complete the remaining registration by adding my payment information, which includes bank account number and routing number, before any invoice payments can be initiated by me or the EFT contact person listed above. This authorization agreement is to remain in full force until EFT payments are no longer required or until CDI and I mutually agree to terminate my voluntary participation in the EFT program.

The person named below has authority to approve the use of EFT transactons for the payment of balances due to CDI.

A copy of this agreement will be returned confirming your enrollment along with instructions on how to create a user profile to begin using the EFT system.

For EFT assistance or questions, email arbilling@insurance.ca.gov or contact us at (916) 492-3242.