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Auto PREMIuM REIMBuRSEMENt INFoRMAtIoN
2
dIREct dEPoSIt ENRollMENt
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Direct deposit is faster and more convenient than waiting to receive paper check reimbursements in the mail. Information you provide below will supersede
any previous direct deposit enrollment on le. A voided check is not required.
REQuIREd PARtIcIPANt SIgNAtuRE AutHoRIZAtIoN
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I (participant) hereby authorize the Plan to disburse funds from my participant account as provided for in this form. I understand that approximately three (3)
months before my account is expected to run out, any portion of my remaining account balance not already allocated to Stable Value will be transferred to protect
my account against losses in case significant negative market changes occur. I hereby agree to hold my employer, the VEBA Plan Trustees, the VEBA Plan,
and it’s service providers harmless for any damages that may occur from following the instructions on this form. I hereby certify that (1) the foregoing statements
are true and correct, (2) the premium amount submitted is the accurate amount of my cost of qualified insurance premiums, and (3) all such persons covered
under the insurance policy are qualified dependents under the terms of the Plan, and (4) premiums for which I am requesting reimbursement are not being paid
by an employer and are not eligible for pre-tax deduction through my employer’s section 125 cafeteria plan. I acknowledge and agree that any claim submitted
fraudulently could result in my termination from the Plan and/or other legal action. I understand that it is my responsibility to notify the Plan if my premium amount
or other information changes. For direct deposits: I hereby authorize and request the Plan to electronically deposit a periodic reimbursement for my insurance
premium(s) to the financial institution designated above or already on file with the Plan. This authorization is not an assignment of my right to receive payment
and revokes all prior payment direction notifications. I understand funds availability is subject to my banking institution’s policies and procedures. I understand the
authorization(s) on this form will remain in effect with VEBA Plan until my account is depleted or until cancelled by written notice from me or my power of attorney.
c
YES
c
NO
PARtIcIPANt AccouNt coNtAct INFoRMAtIoN
1
c
You MUST attach documentation that includes: (1) name(s) of covered individuals or policy holder; (2) premium amounts(s); (3) policy period; and (4) insurance
provider name and address. This information is typically contained on your premium billing notice. If required documentation is not received, your auto premium
reimbursement request will be denied. Premiums paid by an employer, deducted pre-tax through a Section 125 cafeteria plan or subsidized by the
Premium Tax Credit are not eligible for reimbursement. If this reimbursement request is for long-term care insurance premiums, you must include a copy of the
policy’s Declaration page to conrm that the policy is tax-qualied.
NEW AMOUNT
$
OLD AMOUNT
(if this is a change)
$
c
NEW
request
c
CHANGE
to current reimbursement
c
Checking
c
Savings
NAME OF FINANCIAL INSTITUTION (bank or credit union)
9-DIGIT ROUTING NUMBER
(see sample check)
ACCOUNT NUMBER
(do not include check number)
LAST NAME
ACCOUNT NUMBER or SSN DATE OF BIRTH MM / DD / YYYY
FIRST NAME M.I.
EMPLOYER NAME
DATE OF SEPARATION OR RETIREMENT MM / DD / YYYY
c
YES
c
NO
Please check the box
above and enter your email
address at the left to sign-
up for e-communication.
Read details on reverse.
MAILING ADDRESS CITY STATE ZIP
AREA CODE and PHONE NUMBER EMAIL ADDRESS IS REQUIRED (use home or personal email address)
If you are claims-eligible under more than one participant account, enter the participant account number of the account from which you want your auto
reimbursement. Otherwise, your auto reimbursement will be taken from the account with the earliest claims-eligibility date. All information in this section is
required to process your auto premium reimbursement request.
X
PARTICIPANT SIGNATURE DATE MM / DD / YYYY PHONE NUMBER WHERE I CAN BE REACHED
(To occur on
time, request must be received at least 10 days prior to due date)
1st or 15th day of the month
Please make my rst reimbursement retroactive
to my requested due date, if this date is in the
past, or if this request is not received in time.
Monthly
Quarterly
Semi-Annually
Annually
MM / YYYY
Beginning with coverage for month/year of:
VP04 (12/14 PRC)
u
Log in at and submit your request online.
Important reminders and informaon on reverse.
| Fax: (206) 577-3020 | VEBA Plan, PO Box 80587, Seale, WA 98108
| |
