Direct Deposit Authorization Form

Provident Claims Services, Inc.

PO Box 38295

Pittsburgh, PA 15238-8295

Phone: 800.478.1752 | Fax: 412.963.0148

Business Hours: 8:30 AM to 5 PM

Authorization Agreement (ACH Direct Deposit Only). By signing below, I (the "Receiver") authorize Provident Claims Services, Inc. (PCS) (the "Originator") to initiate Automated Clearing House (ACH) credit entries (direct deposits) to the deposit account identified below (the "Account"). This authorization is limited to the direct deposit of claim payment proceeds and any permissible correcting entries related to those deposits.

ACH CREDITS ONLY ACKNOWLEDGMENT

This form is to be used for PCS direct deposit of funds only.

Request Type:

Receiver SS# or FEIN #:

Receiver Name:

Start Date:

Receiver Phone Number:

Please enter a valid phone number.Format: (000) 000-0000.

On behalf of (claimant, minor, etc.)

Receiver Email Address:

example@gmail.com

No Liability for Bank Delays/Incorrect Information. I understand the Originator is not responsible for delays or losses caused by incorrect or incomplete information I provide, actions or errors by my financial institution, or events outside the Originator's reasonable control.

Compliance and Dispute Cooperation. Entries initiated under this authorization will comply with the Nacha Operating Rules and applicable U.S. law. I certify that I am an authorized signer or owner of the Account and authorize my financial institution to provide information needed to resolve any entry, return, or notice of change related to this authorization.

Revocation/Changes. This authorization will remain in effect until the Originator receives my written notice to change or revoke it. Any change or revocation request must be received at least five (5) banking days before the next scheduled deposit date to allow a reasonable opportunity to act.

Notice of Issues. I will promptly review my Account activity and notify PCS if a direct deposit has not been received or if an amount is incorrect. To the extent permitted by law and the Nacha Rules, claims relating to an unauthorized or erroneous entry are subject to applicable reporting timeframes.

Correction, Reversal, and Adjustments for Errors. If an entry is made in error (including an incorrect amount, duplicate entry, wrong account, or wrong effective date), I authorize the Originator to initiate a correcting entry or reversal as permitted by the Nacha Operating Rules and applicable law. The Originator will make reasonable efforts to notify me of any reversal and the reason for it as required by the Nacha Rules.

Account Verification and Receipt of Entries. I authorize the Originator and its financial institution to verify my Account information, including by initiating one or more prenotification (zero-dollar) entries or other commercially reasonable verification methods, and to deposit funds to the Account in accordance with this authorization.

Name of Financial Institution:

Account Type:

Account Category:

Routing Number:

Account Number:

Privacy and Data Use Notice. PCS will use the banking and personal information provided on this form solely for the purpose of initiating and administering ACH direct deposit transactions and for related operational, legal, and compliance purposes. Such information will be maintained and safeguarded in accordance with applicable federal and state privacy and data security laws, including the Gramm-Leach-Bliley Act (GLBA), and will not be disclosed to third parties except as necessary to process ACH transactions, comply with law, or as otherwise permitted by applicable regulations.

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File Types Accepted: pdf, doc, zip, jpg, jpeg, png

Authorized Signature (Primary):

Date:

Authorized Signature (Joint):

Date:

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Direct Deposit Authorization Form

Primary Account Information

Signature