Direct Deposit ACT Bank Change {BWC-0045}

Direct Deposit Act Bank Change Instructions · Please print or type. · Please attach a voided check or deposit slip for the new account. · You must complete all information for us to process this form. · Return this form to BWC Benefits Payable, P.O. Box 15429, Columbus, OH 43215-0429 NOTE: Complete this section if you are changing direct deposit information. Please keep old bank account open until payments are received in new bank account. Bank name *New Bank Information Account holder Bank transit routing number Bank account number Check one Checking Savings Injured Worker Information Injured worker name Current telephone number ( Social Security number Claim number(s) ) Injured worker signature Date Attach voided check or deposit slip here BWC-0045 (Rev. 5/9/2003) A-35 American LegalNet, Inc. www.FormsWorkFlow.com