Broker Commissions - ACH Authorization Agreement Form
Company/Broker’s Name: TIN Number (Tax ID#):
City: State: Zip: Phone:
Contact Name: Title:
Financial Institution Name: Account Owner's Name:
City: State: Zip: Type of Account:
Consumer Checking Corporate Checking
Consumer Savings Corporate Savings
ABA Transit Routing Number: Bank Account Number:
As a convenience to me, I (we) authorize Health Plan of Nevada and/or Sierra Health and Life (HPN/SHL) to initiate
credit/debit entries to the account and financial institution listed above.
This authorization is to remain in full force and effect until HPN/SHL and the financial institution have received
written notification from me (or either of us) of its termination in such a manner as to afford HPN/SHL and the
financial institution a reasonable opportunity to act on it.
Please provide a pre-printed voided check or deposit slip from the account in which commissions will be
deposited in order to facilitate the set-up of the electronic check (ACH) agreement.
Account Owner(s) ___ by Name ___
Title: Signature: Date: ___
WARNING: It is unlawful to knowingly provide false, incomplete, or misleading facts or information to an insurance company for the
purpose of defrauding or attempting to defraud the company, penalties may include imprisonment, fines, denial of insurance, and
civil damages. Any insurance company or agent of an insurance company who knowingly provides false, incomplete, or misleading
facts or information to a policyholder or claimant for the purpose of defrauding or attempting to defraud the policyholder or claimant
with regard to a settlement or award payable from insurance proceeds shall be reported to the Division of Insurance.
P.O. Box 18407 • Las Vegas, Nevada 89114-8407 • (702) 242-7575
Form No. HPNSHL-BComm-ACHAuthForm-2010