Crawford & Company
Restoring and enhancing lives, businesses and communities.
Rev. 6/22/21 NY Direct Deposit Form(w)
Date:
ClaimantName:
DateofLoss:
Employer:
ClaimNumber:
Pleasecompletethisformtodocumentyourrequestthatyourweeklybenefitsbemadebyelectronictransfer.
Tobegin,changeorcancelthetransmittalofworkers'compensationbenefitchecksand/orproceedsfroma
settlementagreementpursuanttoWCL§32(hereinaftersettlementproceeds)directlytoafinancialinstitution:
Downloadandprintthisform.Submittheform,completedinitsentirety,totheattentionofyourAdjusteratour
NewYorkServiceCenterusinganyoftheoptionsbelow.DonotsendtotheWorkers'CompensationBoard.
• MailingAddress:BroadspireNewYorkServiceCenter:POBox14343,Lexington,KY40512‐4343
• EmailAddress:Broadspire.Claims‐NewYork@conduent.com
• Fax:859‐550‐2174
CLAIMANT'SRIGHTSTODIRECTDEPOSIT
• Thisformisoptional,butyouhavetherighttoreceiveyourworkers'compensationindemnitybenefitsor
deathbenefitsintheformofdirectdeposit.Youalsohavetherighttoreceiveyourworkers'
compensationindemnitybenefitsordeathbenefitsbypapercheckinthemail.
• Youhavetherighttocancelthedirectdepositatanytimebycheckingtheappropriateboxonthisform
andforwardingthecompletedformtotheclaimadministratorresponsiblefortheworkers'compensation
claim.Therequestwillbeimplementedwithinforty‐fivedaysofreceiptofnotice,andthereafterpayment
ofbenefitswillbesentbypapercheck.
• BeginningJuly1,2021,youhavetherighttohavesuchpaymentsdepositedintoatleasttwobank
accountsatyourrequest,eitherasapercentageofthetotalbenefitorafixeddollaramountforeach
deposit.Theclaimadministratormayrequireaminimumamountofupto$20intoeachbankaccount.
AUTHORIZATIONS&UNDERSTANDINGS
• Iauthorizetheclaimadministratortodirectlydepositmyworkers'compensationindemnitybenefitsor
deathbenefitsintothespecifiedbankaccount(s).
• Iauthorizetheclaimadministratortodebittheaccountinordertorecoveranycreditsdepositedinerror.
Theclaimadministratormayrecovercreditsdepositedinerrorbyanylawfulmeans.IMPORTANT:This
consentdoesnotauthorizetheclaimadministratortorecoverallegedoverpaymentsofestablishedand
awardedbenefits.
• Iunderstandthatanychangeinmyemploymentstatusmayaffectmyrighttoreceivebenefits.
• Iunderstandthatanyfalsestatementorfailuretodiscloseamaterialfactinordertoobtainorincrease
mybenefitsmayresultincriminalprosecution,disqualificationfrombenefits,andrepaymentofanyfunds
depositedtomyaccount.
• Iunderstandthatthefailuretonotifytheinsurancecarrier,self‐insuredemployer,orthird‐party
administrator(TPA)(claimadministrator)ofanychangeinfinancialinstitutionoraccountmaydelay
receiptofmybenefitsorsettlementproceeds.
• Iunderstandthatinordertochangeorcancelthedirectdepositformyworkers'compensationindemnity
benefitsordeathbenefits,Ineedtosubmitthisformtotheclaimadministrator.
• IunderstandthatIhaveanobligationtoimmediatelynotifytheclaimadministratorifIamnolonger
entitledtosuchpayments,orofchangesincircumstanceswhichaffectmyentitlementtosuchpayment.
• IunderstandthattheclaimadministratormayrequiremetocertifyannuallythatIcontinuetoelectthe
receiptofsuchbenefitsbydirectdeposit,andthatifIfailtodoso,theclaimadministratormay
discontinuedirectdepositandthereafterprovidebenefitsbypapercheck.
Direct Deposit Authorization Form
☐ New Enrollment ☐ Change ☐ Cancel
Depositor/Claimant's Name (last, first):
Phone Number (including area code):
E-mail Address:
Street Address: City:
State: ZIP Code:
WCB Claim Number:
DEPOSITOR/CLAIMANT/JOINT ACCOUNT HOLDER CERTIFICATION
I certify that I am entitled to receive the underlying compensation payments or death benefits and
circumstances entitling me to benefits or death benefits have not changed. I hereby request payment of
my benefits by electronic transfer. I authorize Broadspire and the Financial Institution named below to
credit my account for direct deposit of claim benefit payments and, if necessary, to initiate debit or
adjustment entries for credits made in error. IMPORTANT: This consent does not authorize the claim
administrator to recover alleged over payments of established and awarded benefits. This authority will
remain in effect until I have canceled it in writing. I hereby request payment of my Indemnity benefits by
electronic transfer. I authorize Broadspire and the Financial Institution named above to credit my account
for direct deposit of claim benefit payments and, if necessary, to initiate debit or adjustment entries for
credits made in error. This authority will remain in effect until I have canceled it in writing.
I understand that the claim administrator may request an annual certification of continued
entitlement to such payments or benefits, and that such certification MUST be provided within sixty
days in order to continue payments by direct deposit.
Depositor/Claimant Certification Signature:
Date:
Joint Account Holder Certification Signature:
Date:
SECTION 2
Please check with your financial institution to complete the requested information in this section. Direct
deposit is only available if your financial institution is part of the New York State Automated Clearinghouse.
In addition, the depositor's name MUST appear on the account.
☐ Checking ☐ Savings
Name of Financial Institution Amount or % to be deposited:
Depositors Account Number (EFT Format) :
Routing Number
☐ Checking ☐ Savings
Name of 2nd Financial Institution Amount or % to be deposited:
Routing Number
I understand that any false statement or failure to disclose a material fact in order to obtain or increase my benefits may
result in criminal prosecution, disqualification from benefits, and repayment of any funds deposited to my account.