Horizon Blue Cross Blue Shield of New Jersey
Three Penn Plaza East PP-08S
Newark, NJ 07105-2200
Phone: (800) 224-4426
Fax: (973) 274-2215
HorizonBlue.com/fsa
Services and Products may be provided by Horizon Blue Cross Blue Shield of New Jersey, an independent licensee of the Blue Cross and Blue Shield Association.
AUTHORIZATION AGREEMENT FOR DIRECT DEPOSIT
FLEXIBLE SPENDING ACCOUNT PROGRAM
Yes, please sign me up for FSA Direct Deposit. I hereby authorize Horizon Blue Cross Blue Shield of New
Jersey to initiate deposit to the bank account indicated below. I authorize credit entries and, if necessary, debit entries
and adjustment for any credit entries made in error to my account.
Company Name: ______________________________________________________________________________
Name: _________________________________________________ ID #: ________________________________
Address: ____________________________________________________________________________________
City: _________________________________________ State: ___________ Zip Code: _____________________
Phone #: ______________________________________ Fax #: _________________________________________
Email Address: ________________________________________________________________________________
CHECK ONE: Initial Application Change Cancel
*Attach voided check or deposit slip to this application
__________________________ __________________________ __________________________
Transit ABA Routing # Account Number Account Type
(Checking/Savings)
Name of Bank: ________________________________________________________________________________
Bank Address: ________________________________________________________________________________
Bank Address: ________________________________________________________________________________
______________________________________________________________
Please Print Your Name
______________________________________________________________ ___________________________
Signature Date
This authorization will remain in effect until I have given written notice of its termination or until my employer has
notified me that this deposit service has been terminated. I understand that I must give advance notice to allow
reasonable time for my instructions to be executed.
(10/15)
RESET
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