Wells Fargo - Flexible Benefits Plan Election Form / Salary Reduction Agreement Page 3
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3Wells Fargo of California Insurance Services, Inc.
DIRECT DEPOSIT AUTHORIZATION FORM
For
Flexible Benefits, including Health FSA, DCAP, Transportation, & Adoption Assistance
Use this form to commence, change or cancel your direct deposit with Wells Fargo of California Insurance Services, Inc.
Please allow up to three weeks from the date Wells Fargo Insurance Services receives this form to activate your account.
You will continue to receive regular disbursement checks, if applicable, during this process period.
To process your request accurately,
This form MUST be completed in its entirety, signed, and a “voided” check must be attached
EMPLOYER:
City of Petaluma
Employee Name:
Employee ID Number:
Address:
City:
State:
Zip:
Daytime Phone:
Check Box:
Start Direct Deposit
Change Account
Cancel Account
Check One
Account Type
ABA Number
Account Number
Add
Cancel
(checking or savings)
IMPORTANT: Once a direct deposit has been initiated, you MUST NOTIFY WELLS FARGO INSURANCE SERVICES when
your account is closed, whether it is closed by you or a financial institution. Wells Fargo Insurance Services must receive
notification prior to your next scheduled disbursement.
Authorization Statement: I authorize Wells Fargo of California Insurance Services, Inc. to deposit each reimbursement directly
into my account named above. I understand these instructions will remain in effect until written notification from me has been
received to change or cancel the above information or until Wells Fargo Insurance Services or my financial institution has
notified me that this deposit service has been terminated. This form authorizes Wells Fargo Insurance Services to recover any
compensation or benefits related funds erroneously deposited into my account.
I have accurately completed this form to the best of my knowledge, and have attached a voided check for processing.
Date: ____________________
Signature of Employee: _________________________________________________
FAX:
800-231-3213
Mailing Address:
Wells Fargo of California Insurance Services, Inc.
11017 Cobblerock Drive, Suite 100
Rancho Cordova, CA 95670
Phone:
888-336-7471 – Flex Benefits Department
Attach Voided Check Here
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