Navia Benefits Card/direct Deposit Authorization Form

FORM COMPLETION AND SUBMISSION INSTRUCTIONS

NAVIA BENEFITS CARD/DIRECT DEPOSIT AUTHORIZATION FORM

Form Completion:

Employee Information: complete all fields

Navia Benefits Card Election: Complete if you need a debit card for your medical Flexible

Spending Arrangement (FSA)

Direct Deposit Authorization: Check the checking or savings box and complete the routing #

and account # fields if you need to provide or update your direct deposit information for FSA

and/or DCAP reimbursements (Note: if you do not provide direct deposit information, claims

reimbursement will occur via check, which will be mailed to your address on file with Navia)

Form Submission:

After completion, make a copy for your records and return the original to Navia Benefit Solutions:

Via mail: Navia Benefit Solutions, PO Box 53250, Bellevue, WA 98015

Via fax: (425) 233-6366

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