EFT Request Form

A. BROKER/AGENCY INFORMATION
Broker/Agency

Broker/Agency ID #

Please choose one of the following options:

q Elect EFT Payments

q Change EFT Information

B. Banking INFORMATION
I (we) authorize SelectHealth to initiate credit entries to my (our): q Checking Account

q Savings Account

Name on Account

Account #

Name of Financial Institution

Routing/Transit #

IMPORTANT NOTICE: It is the applicants responsibility to ensure that the information provided on this form is complete and accurate.
SelectHealth will not be responsible and shall be held harmless for errors made in EFT payments that are a result of inaccurate or incomplete
information provided on this form. In no event and under no circumstances will the liability of SelectHealth exceed the amount of the EFT
payments in question.
Account Owner or
Authorized Official Signature

Date

Print Name

Title

REPETITIVE EFT request

Attach a Voided Check Here
Do not use a checking deposit slip for EFT deposits.
Checking deposit slips do not always contain the necessary routing and transit information.

Check#

C. FOR INTERNAL USE ONLY

Approved by (Signature)

Reviewed By (Signature)

Routing & Transit#

Account#

Frequently Asked Questions

What is EFT?
Electronic Funds Transfer (EFT) is a method of transferring payments electronically from SelectHealth directly into
a broker/agencys checking or savings account.
How do I enroll in EFT?
To enroll in EFT, you must complete an EFT Request Form, available on Broker Exchange or by contacting
SelectHealth Broker Commissions at the number or e-mail listed below. To protect the privacy of your financial
information, please do not fax or e-mail completed forms. Please mail your signed and completed forms to the
following address:

SelectHealth
Attn: Janica Blackhurst
Broker Relations
5381 Green Street
Salt Lake City, Utah 84123

When should I expect my first deposit?

Depending on when SelectHealth receives your completed form, you can expect to receive your first payment by
the next payment cycle or the one thereafter.
Will I continue to receive a commission statement once I begin receiving
EFT Payments?
SelectHealth will continue to generate your commission statements. Your statement will be available online via
Broker Exchange two to five days after your account is credited with the funds.
What happens if my account information changes?
In the event that your account information changes, you will need to submit another signed and completed
SelectHealth EFT request form with your updated information and mail it to SelectHealth.
Please contact SelectHealth Broker Commissions with any questions at 801-442-5870
or commissions@selecthealth.org.

2010 SelectHealth. All rights reserved 0391R 05/10