DIRECT DEPOSIT FORM
ManhattanLife Insurance and Annuity Company | The Manhattan Life Insurance Company Standard Life and Casualty Insurance Company | Western United Life Insurance Company 10777 Northwest Freeway, Houston, Texas 77092
I authorize The Manhattan Life Insurance Company, Western United Life Insurance Company, ManhattanLife Insurance and Annuity Company and Standard Life and Casualty Insurance Company (hereinafter the “Company”) to electronically deposit my Commissions directly into the financial institution(s) of my choice as specified below. I understand that my earnings advice will electronically post to Agent Portal or Agent Resource Center. I also authorize the Company to withdraw electronically from my account(s) any sum credited in error. I understand that in the event I incur a commission debt to the Company, it will not debit my account without prior permission from me. This authorization will remain in effect until I provide the Company written notice of its revocation and the Company has adequate time to process the appropriate transactions. I understand the Company is providing this without charge, and the Company will not be held liable for any claims or damages arising, directly or indirectly, from this deposit arrangement.
q New q Change (A voided check or statement containing pertinent banking information, such as bank transit/rout- ing number and bank account number is recommended but not required.) Account Type: q Checking q Savings
Please Check Box
Bank Name__________________________________________________________________ Transit/Routing No._ ______________________ Account No.__________________________
Deposit Account
Payee Name _________________________________________________________________ Agent No. _______________________________ Phone No. ___________________________ Social Security No. _ ______________________ TIN No. _____________________________ Please print name and title of authorizing party______________________________________ Signature of authorizing party (REQUIRED) ________________________ Date____________
Agent Information
Contact Information
Return completed form to: Commissions@ManhattanLife.com
DO NOT USE TO UPDATE POLICY HOLDER BANKING INFORMATION
AllCo-EFT 0425
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