Navia Benefits Card/direct Deposit Authorization Form Page 2
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3STATE OF WASHINGTON
NAVIA BENEFITS CARD/DIRECT DEPOSIT AUTHORIZATION FORM
Employee Information
__________________________________________________________________
______________________________
SSN (or Employee ID if higher-education):
Last Name, First Name
Address
City
State
Zip code
Address Change
Email - REQUIRED FOR DEBIT CARD
DOB (MM-DD-YYYY)
Navia Benefits Card Election
IMPORTANT:
•
You must elect the debit card from Navia Benefit Solutions each year you wish to use it.
•
If you received a card in 2016 and reenrolled in the Medical Flexible Spending Arrangement (FSA) for 2017, your existing
debit card will be loaded with your new elected funds.
•
Do NOT complete the section below if you already elected a debit card on your 2017 Medical FSA/DCAP Enrollment
Form or on the Navia Benefit Solutions website during the PEBB Program’s open enrollment,
November 1–30, 2016.
Medical FSA Debit Card
There is no cost for you to receive the debit card. You must
A debit card that pays for your qualifying medical
provide an email address to use the debit card.
expenses from the Medical FSA
YES, I authorize Navia Benefit Solutions to issue a debit card for my Medical FSA benefit for the 2017 plan year.
YES, I would like an additional card for my spouse or eligible dependent. Please issue an additional card for:
Spouse Dependent
___
Last Name, First Name
I acknowledge that I have read the entire form and agree to follow federal and state rules for this benefit as
explained in the IRS Regulations and in the Medical FSA Enrollment Guide.
X
Employee Signature
Date
Direct Deposit Authorization
IMPORTANT: Do NOT complete the section below if you already provided direct deposit information when you enrolled
on the Navia Benefit Solutions website or on the Medical FSA/DCAP Enrollment Form during the PEBB Program’s open
enrollment November 1–30, 2016. DO complete this section if your direct deposit information has changed, or if you did not
provide your direct deposit information during enrollment.
Direct Deposit
Routing #
Checking
Medical FSA and DCAP reimbursements are
Savings
Account #
electronically deposited into your bank account.
This direct deposit authorization will remain in full force and effect until Navia Benefit Solutions has received
written notification from me of its termination in such time and in such manner as to afford Navia Benefit Solutions
and the banking institution a reasonable opportunity to act on it.
YES, I authorize Navia Benefit Solutions to electronically deposit my Medical FSA reimbursements into the above
specified bank account.
X __________________________________________________________________________________________________
Employee Signature
Date
Customer Service: (425) 452-3500 or (800) 669-3539 Visit our website at
Please read next page for important information about direct deposit and the debit card.
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