Authorization Agreement for Invoice Payments CDI-177: Fill out & sign online

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How to use or fill out Authorization Agreement for Invoice Payments CDI-177

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Click ‘Get Form’ to open it in the editor.
In Section I, enter your company information clearly. Ensure that the company name and ID number match those on your invoices. If applicable, include your NAIC number.
Proceed to Section II and provide the contact details of the person responsible for creating a user profile and initiating EFT payments. This includes their name, title, email address, and phone number.
In Section III, fill in the representative's details who will approve the ACH Debit payment method. Include their signature, title, printed name, email address, date, and phone number.
Finally, review all sections for accuracy before submitting. Email the completed form to arbilling@insurance.ca.gov as instructed.

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