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RenewElect-PR-1212Renewal Election FormEmployer Group: Two Rivers Public School DistrictEnrollment Effective Date: 7/1/2022New Group Number: ______17JOO4U________________________Subscriber Name: ________________________________ (Please Print)Plan Election (select one):____ HMO HDHP $7,000 / 100% ( plan year deductible)____ POS HDHP $7,000 / 100% (plan year deductible)_____ Waiving Coverage Subscriber Signature DateNote: This form is used to select a different plan at renewal time only. All other changes must be submitted by completing a full Employee Application for Group Coverage. This plan election is for one year. Unless otherwise changed or revised by this form, the terms of your original Employee Application for Group Coverage remain in effect. Return Form to HR.
Complete and return this form to have EBC reimbursements deposited into your checking or savings account. Be sure to sign and date it. You can also authorize Direct Deposit bylogging into My Account Assistant choosing “Acvate Direct Deposit” from the menu.AuthorizationNew Direct Deposit AuthorizaonChange Direct Deposit Authorizaon Cancel Direct Deposit AuthorizaonAccount Holder Information Last 4 Digits of Social Security or Identification Number (Required)Last Name Sux First Name MIE-mail Address (we do not share your e-mail address) EmployerHome Phone Number (000-000-0000) Work Phone Number (000-000-0000)Financial Institution InformationFinancial Instuon BranchCity StateAccount Type:CheckingSavingsRoung Number (exactly 9 digits from check) Account Number (from check)In most cases, the routing number precedes the account number. If in doubt, contact your financial institution.Depositor CertificationI authorize Employee Benefits Corporation to send reimbursements (and appropriate adjusting entries) electronically or by any other commercially accepted method to my designated account at the financial institution named above. I agree not to hold Employee Benefits Corporation responsible for any delay or loss of funds due to incorrect or incomplete information supplied by me or my financial institution or due to an error on the part of my financial institution in depositing funds to my account. It is my responsibility to notify Employee Benefits Corporation immediately of any changes in my financial institution (i.e., change of account number or closure of account). This authorization will remain in effect until Employee Benefits Corporation has received written notification from me of its termination in such time and in such manner as to provide Employee Benefits Corporation a reasonable opportunity to act on it.Account Holder Signature (Required) Date (mm-dd-yyyy)Conditions of ParticipationParcipants in the BESTex Plan and EBC HRA have the opon to have their authorized reimbursements deposited directly into their personal checking or savings account. It is an oponal convenience called Direct Deposit. If you have any quesons regarding your electronic transfers, call Parcipant Services at 800 346 2126 or 608 831 8445.• If you decide to enroll in Direct Deposit, you must complete this authorizaon form or you may acvate Direct Deposit online from My Account Assistant.• If you are enrolled in both the BESTex Plan and EBC HRA, both of your accounts will be updated with this Direct Deposit informaon.• The agreement represented by this authorizaon will remain in eect from one plan year to the next. To cancel it, you must complete a new Direct Deposit Authorizaon Form as a cancel transacon.• It is your responsibility to nofy us immediately of any changes in your nancial instuon (i.e. change of account number, closure of account, etc.). • To nofy us of the change, use the Direct Deposit Authorizaon Form. Mark the “Change” box in the Type of Transacon entry above. We will process these changes immediately upon receipt of the form. Since changes of this type usually take four business days to complete, please plan accordingly. • Your electronic transfer will be made directly into your account. If your nancial instuon cannot make this transfer within three business days of receipt, we will invesgate, then issue and mail a reimbursement check to you. Unl the electronic transfer problem is resolved, you will connue to receive reimbursement checks in the mail. Reinstatement of Direct Deposit will be determined on a case-by-case basis and you will be noed if it occurs. • Your nancial instuon may also cancel this agreement. In such cases, you will receive reimbursement checks in the mail.© Employee Benefits Corporation 9012 1CDirect Deposit Authorizaon Phone support: 800 346 2126 | 608 831 8445E-mail: parcipantservices@ebcex.com