E-Statement Enrollment Form

To sign up for E-Statement Notice Delivery, you must be an owner of the accounts at Brunswick State Bank. You will no longer receive a paper Statement. Your Statements are on-line to review within Internet Banking.

First Name:*
Last Name:*
Suffix:
Business Name:	If applying for a business account.
Address:*
City:*
State:*
ZIP* - Plus 4:	- ZIP Plus Four
Phone Number:*	- Phone Prefix - Phone Suffix
Email:*	Please contact the bank if your e-mail address changes.
Confirm Email:*
Activate the following accounts for E-Statements:*
Primary Account Number:*
	Primary Account Type:
Additional Account
	Additional Account Type:
Additional Account
	Additional Account Type:
Additional Account
	Additional Account Type:
Additional Account
	Additional Account Type:
Additional Account
	Additional Account Type:
Additional Account
	Additional Account Type:
For E-Statements In order to complete the enrollment, you must view the sample E-Statement to ensure you'll be able to view your E-Statement. Click on the sample E-Statement link below and find the authentication code necessary to complete this enrollment form. The authentication code is located at the top of the sample E-Statement. *Enter the case sensitive authentication code (found in the sample E-Statement)
Electronic Delivery of Statements and Notices By accepting the “Brunswick State Bank Electronic Statement (eStatement) Disclosure Agreement”, you consent and agree that Brunswick State Bank may provide certain disclosures and notices to you in electronic form, in lieu of paper form, including electronic delivery of statements (eStatements) for your Brunswick State Bank deposit account(s). Consent to Electronic Delivery of Notices User agrees that any notice or other type of communication provided to User pursuant to the terms of this agreement, and any future disclosures required by law, including electronic fund transfer disclosures, may be made electronically by Email. Bank may send all notices, attachments, and/or documents via Email to the last known Email address provided by you. User agrees to notify Bank promptly of any change in Email address. To discontinue paper statements you must enroll each of your deposit account(s) for which you want to have eStatement Notices. To enroll your account(s) for eStatements notices simply sign up online under Secure Forms, complete the eStatement enrollment form and submit. To access your eStatements, you must log in to Brunswick State Bank’s Online Banking service, choose the account you want to view then: 1) Click on the “Documents” tab, 2) Select the date range that you wish to view, 3) Submit - Your eStatement(s) will be viewable as an easy to read Adobe® PDF file. You may download the latest version of Adobe® Reader® for free at www.adobe.com. By submitting this form, I authorize the bank to send future estatement notices for the above – mentioned accounts, for which I am an owner, to the email address listed above and to receive notices electronically. I understand that authorizing this E-Statement Notice Service I will no longer receive paper statements. You have the right to withdraw your consent to have your statements provided in an electronic form by calling us at (888) 393-7945. You may also write us at P.O. Box 29, 226 2nd St. Brunswick, NE 68720. We will then discontinue eStatement notice service for that account and you will receive paper statements for subsequent statement periods. There is no fee to discontinue your eStatement notice service, but to revert to receiving paper statements for your account(s) there will be a monthly statement fee. Please Review the Full Terms and Conditions at the link below before you accept this agreement. ELECTRONIC STATEMENT, (eStatement), DISCLOSURE AGREEMENT Please print this disclosure for your records.
*Required Information

E-Statement Enrollment Form

Activate the following accounts for E-Statements:*

For E-Statements

ELECTRONIC STATEMENT, (eStatement), DISCLOSURE AGREEMENT