Payment Deduction Form

Fill This form out completely and submit to Compass Rose Benefits Group in one of the following ways:

By using your IC "Internal" fax and sending it to 703-613-7807
By using an external commercial fax at 703-734-7013
Send by mail external mail (USPS) to the following address

Benefits Group
P.O. Box 8816
Reston, VA 20195

Full Name ___________________________________________________________ (please print clearly)

First MI Last Suffix

Signature_____________________________________________________________

IC Agency ___________________________________________________________

Home Mailing Address __________________________________________________________________

Routing Number ___ ____ ____ ____ ____ ____ ___ ____ ____

Routing Number: This number must start with a 0, 1, 2 or 3. This series of numbers MUST be 9 digits.

Account Number ___ ___ ___ ____ ____ ____ ____ ____ ____ ___ ___ ___ ___ ___

Account Number: Include all leading zeros. Omit any spaces or characters.

(your account number may not be this long)

Please indicate whether this is to come from your checking or savings account. ________________

Email Address: ______________________________________________________

(Email Address: Be sure to include the full email address Example: john_doe@acme.com)

Day Time Phone Number ( ) _____ - _____ extension ____

UBLIC Term Life Insurance $____________________

Employee Long Term Disability Insurance $____________________

Group Accident Plan $____________________

To locate the Account and Routing numbers, please see sample below.