Company Bank Account Change Form

Company Name*

Company ID*

Contact Name*

Contact Email*

YesNo

New Account Information*

List the account number of the bank account that will be replaced:

Starting check number:*

Entire CompanySpecific Department(s) - List below

List the departments/cost centers this bank account will apply to:*

*Only applies if CBIZ is administering your COBRA and/or Flexible Benefits

Company Address to be listed on account (if different from legal address):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Attach Voided Check(s)*

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Effective Check Date

MonthDayYear

Yes, use existing signatureYes, I will sign belowYes, I will upload a copy of my signatureNo

Upload signature copy:

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Check Signature:*

I (we) hereby authorize CBIZ HCM, to initiate debit entries and to initiate, if necessary, credit entries and adjustments for any credit entries in error to my (our) checking or savings account indicated depository name above, hereinafter called Depository, to credit and/or debit the same to such account. This authority is to remain in full force and effect until CBIZ HCM has received written notification from me of its termination in such time and in such manner as to afford CBIZ HCM and Depository a reasonable opportunity to act on it.

By submitting this form, I approve the setup of the requested bank accounts. I assume any related liability in the event that the information provided is found to be inaccurate.Please note that there is a five business day prenote for bank account changes, if you plan to process your payroll before the 5-day business prenote; we will either have to draft the previous account or you will need to wire funds.

Company Bank Account Change Form

Enter Account Information