Recurring Payment Authorization form

Clients forms

RECURRING

PAYMENT

AUTHORIZATION

FORM

Here’s how recurring payment card (credit card / debit card) payments work.

• You authorize OCMI Workers Comp to process your debit/credit card every time your payroll is processed and service fees are due

• You authorize OCMI Workers Comp to process the amount reflected on your invoice/s, which will vary depending on your services.

• A convenience fee of 1.55% will be added to your total invoice amount.

• The record will appear on your bank statement as “OCMI Workers Comp”.

• You agree to notify OCMI Workers Comp if there are any changes to your billing information at least 5 business days prior to your next billing date.

Clients forms

Workers comp certificate request

Employee onboarding

Employee time reporting

Recurring Payment Autorization

Client Authorization to Debit/Credit

Direct Deposit

Client Affidavit Of Zero Wages

Separation Notice

Workers Comp Claim Kit

Your Information

Card Holder Name

Company Name

Card Number

Card Expiration Date

Card CVV

Phone Number

City

Address

State

Zip

Accept, see our Disclaimer.

Disclaimer

IMPORTANT:

I am responsible to have all necessary funds on hand and fully fund all charges processed by OCMI Workers Comp on my behalf. I am responsible for any and all losses, liabilities and related recovery expenses that may occur due to incorrect data, rejected transfers, insufficient funds, unlawful activity and any unauthorized charges on my credit/debit card. I acknowledge that if sufficient funds are not available to process the charges for the service fees, OCMI Workers Comp may first process any funds needed through my credit/debit card on file with OCMI Workers Comp, and if funds are not available, (1) I will immediately become solely responsible for all tax deposits and filings, all wages due, all wage garnishments, and all related penalties and interest due then and thereafter, (2) any and all OCMI Workers Comp services may, at OCMI Workers Comp’s option, be immediately terminated, (3) OCMI Workers Comp and its financial institutions and agents will not have anyfurther obligation to my or any third party with respect to any such services, and (4) OCMI Workers Comp may take such action as it deems appropriate to collect OCMI Workers Comp’s fees pursuant to the Professional Employer Service Agreement.

AUTHORIZATION:

I, the undersigned, authorize OCMI III, Inc. d/b/a OCMI Workers Comp and its financial institutions and agents to charge my credit or debit card listed above and pay the service fees required and agreed upon in my Professional Employer Service Agreement. The amount charged may represent scheduled or periodic charges for any and all fees associated to my Professional Employer Service Agreement, including, if necessary, adjustments for any changes to my account. I understand that my recurring service fees may vary. I agree and understand that I may be subject to additional fees, penalties or cancellation if my service fees cannot be processed for any and all reasons. I agree that the periodic charge(s) will be applied to my credit/debit card according to my reporting billing cycle, and in order to cancel the recurring billing process, I am required to contact OCMI Workers Comp one (1) month in advance to arrange for an alternative method of payment. I understand that OCMI Workers Comp is not required to provide to me any invoices or bills prior to the billing cycle. I agree that if I have any problems or questions regarding my account or any services provided by or through OCMI Workers Comp, I will contact OCMI Workers Comp for assistance. I also agree that I will not dispute any charges with my credit/debit card company and agree, accept and acknowledge that all fees are non-refundable. I guarantee and warrant that I am the legal cardholder for this credit/debit card and that I am legally authorized to enter into this recurring credit/debit card authorization agreement with OCMI Workers Comp.