Direct Deposit Authorization

We would love to hear from you! Please fill out this form and we will get in touch with you shortly.

AUTHORIZATION FOR AUTOMATIC DEPOSIT:
I hereby authorize Washington Law Center (full address below) and its associates to direct deposit my time loss, loss of earning power, pension, permanent partial disability, back time loss and time loss adjustments, or any other form of payment or compensation received in for my workers’ compensation claim, in to the bank account which I will indicate below. Once this system has been put into place this service will be preformed automatically. I understand it is the client’s responsibility to inform Washington Law Center of any changes to the account or direct deposit information. Should the funds be returned to Washington Law Center for any reason a check will be issued along with the documentation via regular mail to my last known address. This form only authorizes Washington Law Center to make deposits into my account. No other actions are being authorized. Finally, I understand that I can stop this service and have a check mailed out at any time, however, I must inform Washington Law Center of this request three days prior to the arrival of the expected funds.
Washington Law Center

651 Strander Blvd

Building B, Suite 215

Tukwila, WA 98188

Tel: (206) 596-7888

Fax: (206) 457-4900
Name on Account (Must Match Client Name):
Name of Bank:
Checking
or Savings
Account Number:
Routing Number:
Client Signature:
Date:
MM slash DD slash YYYY