Appendix D - Authorization Agreement for EFT
The Authorization Agreement For Electronic Funds Transfer is now available in Microsoft EXCEL 2000 and/or in Adobe's Portable Document Format (PDF). The Excel document may be downloaded to your computer. To view and complete the PDF form on your browser, you must have Adobe Acrobat Reader 5.0 or higher on your computer. A free copy of the Adobe Acrobat Reader can be downloaded from our Free Document Readers webpage.
Type or print clearly. Return to the California Department of Insurance, Accounting Services Bureau, Tax Accounting/EFT at 300 Capitol Mall, Suite 14000, Sacramento, CA 95814. Retain a copy for your file before mailing.
Complete this section for any type of transaction. For change of address, complete Section I only and sign.
- The EFT TIN # is assigned when your EFT account is established. The California Department of Insurance will notify you when your EFT TIN Number is assigned.
- The CDI Identification Number is your California Department of Insurance assigned permanent number or the Surplus Line Broker license number.
Complete Section II if you select to make payments using the ACH Debit method. Complete Section III if you will make payments using the ACH Credit method. COMPLETE ONE OF THESE SECTIONS, NOT BOTH.
If the ACH Debit method is chosen, you will be provided a generic security code and an EFT TIN number. And you are required to go to First Data's payment website at www.govone.com/PAYCAL to complete the remaining registration by adding your payment information which includes your bank account number and routing number.
- Participation in the Electronic Funds Transfer program shall be for a minimum of one year.
- You will receive notification from the California Department of Insurance (CDI) upon approval of this agreement.
- You must make a written request and be approved by CDI to be removed from the Electronic Funds Transfer program.
- For the request to be removed from the Electronic Funds Transfer program, you must have participated in the program for a minimum of one year and your last year's annual tax liability must be less than $20,000.
- If you have any questions about the Authorization Agreement or the Electronic Funds Transfer program, please contact the Department of Insurance's Electronic Funds Transfer Unit at (916) 492-3288 or e-mail at email@example.com.