Employee Direct Deposit Authorization Form (Page 2 of 2) in pdf

TERMS AND CONDITIONS FOR PARTICIPATING IN

THE DIRECT DEPOSIT PROGRAM FOR

COMPANY NAME:___________________________________________

REIMBURSEMENT ACCOUNTS

You have the option of (1) having your authorized reimbursements for your Reimbursement Account(s) deposited directly into your

account at your financial institution or (2) receiving a check for any authorized reimbursements. If you do choose to participate in this

Direct Deposit Program (Program), you will need to complete this Authorization Form (Form) and return it to the address below.

Please read the following terms and conditions for participation carefully before making your decision.

1. Your financial institution must be a member of an Automated Clearing House before you can participate in any direct deposit

program. Call your bank to make sure they will accept direct deposits.

2. This Form must be signed and dated and returned to the address below before you can participate in this Program. If you

have a joint account, the form must be signed by both parties.

3. Once the Form is received by Aetna, there may be a 2 reimbursement cycle delay before the reimbursements begin

being deposited directly into your account. You will receive checks for any reimbursements before that time.

4. You will be notified when an electronic transfer is made to your account in a manner set by your employer. The standard

turnaround time between the time the funds are transferred and they have been deposited in your bank is two banking days.

Make sure the deposit has been made to your account before you withdraw the funds.

5. If an electronic transfer is returned to Aetna or cannot be made to your account, Aetna will investigate the cause. If the

situation cannot be resolved quickly, a reimbursement check will be mailed to you. You will continue to receive your

reimbursements by mail until the situation is resolved. You will be notified of any action taken.

6. It is your responsibility to notify Aetna of any changes to your account immediately. Complete this form indicating that

the action is a CHANGE, and return it to the address below. Once received, again there may be a delay of up to four weeks

before the new information will be processed. You will receive checks for any reimbursements before that time.

7. You can cancel participation in Program at any time. To cancel participation, complete this Form indicating that the

action is a CANCEL, and return it to the address on the front. Your participation will be cancelled as of the effective date on

the Form or as soon as the Form has been received and processed, whichever one is later.

8. This agreement may be cancelled by your financial institution or Aetna. Your participation will be cancelled automatically

if your employment is terminated or if you terminate participation in the above Account(s).

9. You do not have to submit a new Form for a Plan Year if you re-enroll in the above Account(s). Your participation will

continue from Plan Year to Plan Year until you terminate your participation or you do not re-enroll in the Account(s).

Please send all completed forms documentation to:

Aetna

10275 W. Higgins Road, Suite 500,

Rosemont, IL 60018

Phone (866) 472-0897 – Fax (847) 332-0335

Aetna-Direct Deposit-11.09

Employee Direct Deposit Authorization Form Page 2