Authorization Agreement for Invoice Payments CDI-177 Preview on Page 1

Authorization Agreement for Invoice Payments CDI-177 2026

The document is an Electronic Funds Transfer (EFT) Authorization Agreement for invoice payments issued by the California Department of Insurance. It outlines the process for companies to authorize EFT payments, including sections for company information, EFT contact person, and ACH debit payment method. The agreement must be completed and submitted to participate in the EFT program, which allows for electronic payments of balances due to the department. Instructions for completing the form and important information regarding payment methods and withdrawal are also provided.

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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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