Insurance Policy Payroll Deductions IMPORTANT: Please complete and submit one of the forms below as applicable.Name* First Last Phone*Email Address* Signature*Please type your First and Last NameCounty Employee Number*Acknowlegement* I understand that checking this box constitutes a legal signature and warrants the truthfulness of the information provided in this form.Please choose an option below*Check this box if you purchased insurance from the PPOA Insurance Agency and you have noticed a deduction from “SFA” on your paystub that you did not authorize.Check this box if you purchased insurance from the PPOA Insurance Agency and you were subsequently contacted by a CRC representative who may have misrepresented themselves, or who asked you to authorize a change in payroll deduction without explaining the payroll move was away from PPOA and to the Stentorians and you submitted an authorization form.I, « Employee Name » « County Employee Number », purchased insurance (e.g. Combined, TransAmerica, Boston Mutual) from the PPOA Insurance Agency and did not authorize any entity to transfer and/or duplicate my insurance policy payroll deductions. PPOA is the only entity I have authorized to make such payroll deductions. This letter provides notice to the Stentorians, CRC, Mike Slade as well as Combined, TransAmerica and Boston Mutual Insurance Companies, that I only authorize PPOA to payroll deduct my insurance premiums. I hereby demand that the aforementioned immediately stop any transfer and/or duplicate payroll deductions through any other entity other than PPOA and immediately refund any monies deducted without my permission.I, « Employee Name » « County Employee Number », purchased insurance (e.g. Combined, TransAmerica, Boston Mutual) from the PPOA Insurance Agency and was contacted by a CRC representative to authorize the movement of my payroll deduction from PPOA to the Stentorians (SFA). This notice is to inform CRC, Stentorians, and Combined, TransAmerica and Boston Mutual Insurance Companies that I rescind my authorization and demand you return my deductions to PPOA. I want to ensure I have the support and backing from PPOA for my insurance needs and do not want my insurance business moved to any other entity.CommentsThis field is for validation purposes and should be left unchanged. This iframe contains the logic required to handle Ajax powered Gravity Forms.