RECURRING PAYMENT AUTHORIZATION FORM

• 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.