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ERS GI-1.220 (R 05/2005) AUTOMATIC WITHDRAWAL OF GROUP BENEFITS PROGRAM (GBP) INSURANCE PREMIUM
 

Summary: ERS GI-1.220 (R 05/2005)
AUTOMATIC WITHDRAWAL OF GROUP BENEFITS PROGRAM (GBP) INSURANCE PREMIUM
GBP Member Information
________________________________________________________________________ ___________________________
Member Name (Last, First Middle Intial) Social Security Number
____________________________________________________________________ ___________________
Address (Street, P.O. Box, APO/FPO, City, State, Zip) Telephone Number
FinancialInstitutionandAccountInformation
Member's Signature:_____________________________________________________ Date:____________
(Guardian may sign for minor children)
__________________________________________________________ _____________________________
Name of Financial Institution Telephone Number
________________________________________________________________________________________
Address of Financial Institution
__________________________ _____________________________________________ _______________
Account Owner's Printed Name Account Owner's Signature Date
Information provided to the Employees Retirement System of Texas (ERS) is maintained for administration of your benefits. If you have
questions about your information, or believe that information provided to ERS may be incorrect, please notify ERS.
Please contact your financial institution if you
havequestionsregardingyourRoutingNumber.

  

Source: Azevedo, Ricardo - Department of Biology and Biochemistry, University of Houston

 

Collections: Biology and Medicine; Environmental Sciences and Ecology