Workers' Compensation > For Employers > EFT Enrollment Form

Instructions For The Completion Of The Second Injury Fund Electronic Funds Transfer Enrollment Form

Completing The Enrollment Form:

You are to complete the unshaded portions of the enrollment form. Please complete the fields of the form with the following information:

NOTE:  Please include a copy of a voided check as verification of account information.

Download The Electronic Fund Transfer Enrollment Form. (PDF)

(This form is semi-interactive and may be filled out online.)