Western Growers Assurance Trust Employee Eligibility System
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Please print this completed form, sign, date and print your name and title and return to the address at the bottom of this page.
After we receive your signed form, we will activate your account and send you a confirmation email.
Sign up for Online Billing and Payments
Which of your Company's Groups would you like to pay online? (Please check those that apply)
All my Groups
Only these Groups:
Email(s) (monthly invoices will be sent here):
Phone (in case we have questions):
You're almost done!
Please print, sign and date this form.
Signature of Authorized Representative: By signing below, I am authorized by the Company to accept, and hereby authorize Western Growers Assurance Trust to send paperless invoices at the above listed email address and agree that the Company will pay electronically such invoices for the Group(s) indicated above.
Authorized Representative Signature
Print Name and Title
Submit via mail:
Attn: Administration Department
Western Growers Assurance Trust
P.O. Box 7070
Newport Beach, CA 92658
or Submit via Fax to:
or Submit a scanned copy of this form via Email to: