STATE OF NEW YORK
WORKERS' COMPENSATION BOARD

DIRECT DEPOSIT AUTHORIZATION FORM
Directions: To begin, change or cancel the transmittal of workers' compensation benefit checks and/or proceeds from asettlement agreement pursuant to WCL § 32 (hereinafter settlement proceeds) directly to a financial institution: fill out
the form on your insurer or administrator's website and submit the form directly to them. Do not send to theWorkers' Compensation Board. If you need a paper copy of the form, please contact your insurer.
CLAIMANT'S RIGHTS TO DIRECT DEPOSIT
This form is optional, but you have the right to receive your workers' compensation indemnity benefits ordeath benefits in the form of direct deposit. You also have the right to receive your workers' compensationindemnity 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 andforwarding 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. Theclaim 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 ordeath 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: Thisconsent does not authorize the claim administrator to recover alleged over payments of established andawarded 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' compensationindemnity benefits or death benefits, I need to submit this form to the claim administrator.

DD-1 (5-21)

oI understand that I have an obligation to immediately notify the claim administrator if I am nolonger entitled to such payments, or of changes in circumstances which affect my entitlement tosuch payment.

oI understand that the claim administrator may require me to certify annually that I continue toelect 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.
www.wcb.ny.gov

DIRECT DEPOSIT AUTHORIZATION FORM
Do not send to the Workers' Compensation Board.
 NEW ENROLLMENT CHANGE CANCELSECTION 1 (TO BE COMPLETED BY CLAIMANT)
Depositor/Claimant's Name (last, first):

WCB Claim Number:Phone Number (including area code):E-mail Address:

Address:

DEPOSITOR/CLAIMANT/JOINT ACCOUNT HOLDER CERTIFICATIONI 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 understand that the claim administrator may request anannual 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 isonly available if your financial institution is part of the New York State Automated Clearinghouse. In addition, thedepositor's name MUST appear on the account.
Name of Financial Institution:

Account Type: Checking

 Savings

Amount or Percentage to be deposited:

Depositor's Account Number (EFT Format):Routing Number:

Name of Second Financial Institution:

Account Type: Checking

 Savings

Amount or Percentage to be deposited:

Depositor's Account Number (EFT Format):Routing Number:

Please note: the direct deposit form is only available for injured workers whose workers’ compensation claim isfiled in the State of New York.
Please return the completed and signed direct deposit form to the Tokio Marine Claim Adjuster handling your claim. You
can email the forms directly to your handling Claims Adjuster, or you can mail the completed forms to the attention ofyour adjuster at: PO Box 483 Jersey City, NJ 07303
Your Claim Adjuster may also contact you upon receipt to verify information.
Please include with the completed and signed direct deposit form, a verification page from the Financial Institution that
identifies bank routing number and bank account number of the depositor. Such verification page can be a deposit slip,
a copy of void check, a copy of a bank letter or statement that included bank routing number and Depositor's bankaccount number.
DD-1 (5-21)