State Workers’ Insurance Fund

Prepaid Debit Card Enrollment Form

You can choose how you receive your SWIF Workers’ Compensation payments. This form is dedicated to Money Network® prepaid debit card enrollments only. If you are seeking direct deposit, please complete the Direct Deposit Authorization Form.

For more information please visit: www.dli.pa.gov/swif

Required fields are marked with an asterisk.(*)

Money Network® Selection and Acknowledgement

Money Network® prepaid debit card

I Authorize

I Acknowledge

What is the purpose of this enrollment?

Enrolling in a payment option for the first time
Changing my payment option

Claimant Enrollment Information

First Name

Middle Initial

Last Name

Date of Birth (MM/DD/YYYY)

Social Security Number

Daytime Phone

Address Line 1

Address Line 2

City

State

Zip Code

Claim Number

Signature

I Accept

Date

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