eflexgroup.com - COBRA, HRA, MERP, POP, HSA, and FSA Administration

eflexgroup.com, inc.
Direct Deposit Authorization Form
2740 Ski Lane • Madison, WI 53713
Phone: 608) 243.8277 • Fax: (608) 245.9342

Email
Employee Name
SSN
Address
City State Zip
Employer Name
 

I request my Section 125 reimbursement direct deposit be placed in the following account:

Institution Name

 Bank ABA Number Account Number Type of Account

Savings   Checking
For security and validation please re-enter the above information

Institution Name

 Bank ABA Number Account Number Type of Account

Savings   Checking

 

The Bank ABA Number is the first nine numbers located on the bottom of your check, shown by Arrow #1.  Your Account Number is the next 8 or 9 numbers indicated by Arrow #2.  Please do not include the final  four numbers, which indicate the check number.  

   
By entering my initials in the box below:

I Authorize my Section 125 Health FSA, Dependent FSA or Individual Health Premium Reimbursements to be sent to the financial institution named above to be deposited in the designated account.

In the event funds are deposited erroneously into my account, I authorize my Section 125 provider to debit my account not to exceed the original amount of the credit.

I also understand that all direct deposits are made through the automated clearing house (ACH) and that funds availability is subject to the terms and limitations of the ACH as well as my financial institution.
Employee Initials Date
ACH Authorization cannot be completed without a copy of your check.