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Make a Payment

Phone 800.686.6640 · Fax 517.664.2787

We are pleased to handle your internet payment request. In order to process this transaction, the following information must be provided and the form must be signed by an authorized signer on the account from which payment is to be drawn.

The check number you provide will serve as your confirmation number. Please remember to void that check and record the withdrawal in your check register. A miscellaneous withdrawal will appear on your bank statement. Michigan Institute of Laundering and Drycleaning Self-Insured Workers’ Compensation Fund will appear as the description for the withdrawal. Please submit this form or print a copy and fax it back to 517-664-2787.

Withdrawals can be processed on any date of your choosing. It is your responsibility to ensure that the date chosen does not result in a past-due payment. Authorized withdrawal dates which fall on a Saturday, Sunday or legal holiday will be processed effective the next business day and will not be considered late. Withdrawal requests that are rejected by your financial institution as a result of non-sufficient funds are subject to a non-sufficient funds fee and may result in immediate cancellation of your coverage.

Michigan Institute of Laundering and Drycleaning Self-Insured Workers’ Compensation Fund is committed to the safe and secure handling of your personal and business information. This payment link transmits through a secured site to assure the privacy of your banking information.

I have read and understand the terms of the internet payment request.

* Member # Code:
* Client Name:
* Name as it appears   on the bank account:
* Bank Name:
* Routing Number:
* Bank Account Number:
* Check Number:
* Payment Amount:
* Payment Type:	One Time Payment Recurring Payment Withdrawal Date:
Special Instructions
* Electronic signature required. Please print your name in the box, this will be your signature: