PO Box 7466 Portland ME 04112-7466
Tel 888 299 2070
Fax 888-505-8550
Claims Department
Direct Deposit Agreement
For Payment of Benefit to Financial Institution
Section 1 (to be completed by benefit recipient)
Name of Benefit Recipient
UHCSB Disability Claim Number UHCSB Policy Number
Social Security Number Telephone Number
Address (Number, Street, Route, P.O. Box, APO/FP, including directional such as NE, NW, SE, SW etc)
City State Zip (prefer
ably the nine digit ZIP code)
"I authorize UnitedHealthcare Specialty Benefits to direct the net amount of my benefit payment to be
deposited directly by electronic funds transfer and credited to my account as indicated at the financial
institution designated below. If any payments made are dated after the date of my death, I hereby
authorize and direct the said financial institution on my behalf and on behalf of my executors or
administrators to refund any such payments to UnitedHealthcare Specialty Benefits and to charge the
same to my account."
PLEASE ATTACH A VOIDED BLANK CHECK TO THIS FORM
Signature of Benefit Recipient (eSignature is allowed) Date Signed
Section 2
Name of Financial Institution
Address ((Number, Street, Route, P.O. Box, APO/FP, including directional such as NE, NW, SE, SW etc)
City State Zip (prefer
ably the nine digit ZIP code)
Routing Num
ber (9 digit number in lower left corner of check)
Bank Account Number (numbers following the Routing Number)
Type of Account Checking Savings (check one)
(
02/2020)
click to sign
signature
click to edit
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