Direct Deposit Form

in Form

Please fill out the form below. Click the PREVIEW button located at the bottom of the form to check whether the form has been filled out completely. If so, then the PRINT PAGE button will allow you to print and add signatures.

All information on this form is confidential.

Send This Claim To:
PBAS
110-61 International Blvd.
Toronto, ON M9W 6K4


DIRECT DEPOSIT FOR DENTAL CLAIMS PAYMENT ENROLMENT/CHANGE FORM

Please complete this form if you would like to elect to have direct deposit, make a change to your direct deposit information or terminate your direct deposit. Direct deposit is a convenient and secure way to have your claims payments deposited into your bank account without having to wait for the mail or make a trip to the bank.

Initial Request Change Termination
Plan Member Last Name*
First Name*
Social Insurance Number*
Mailing Address*
City*
Province*
Postal Code*
E-mail Address*
Cell Phone Number
Home Phone Number*

* In order to participate in Direct Deposit you must receive your EOB by email. An electronic Explanation of Benefits (EOB) showing what has been paid will be emailed to you at the same time a Direct Deposit is made to your bank account.

Bank Account Holder’s Name (if different from Plan Member)
ATTACH A “VOID” CHEQUE HERE
OR, have your financial institution complete the following bank account information, or provide the appropriate Direct Deposit Form from your Bank:
Name of Financial Institution
Address of Financial Institution
Branch (Transit) Number (5 digits)
Bank Number (3 digits)
Account Number (maximum 12 digits)

I hereby authorize the UFCW Trusteed Dental Fund, and its Administrators and Service Providers, to deposit claims payments to my account as indicated above. I understand this information will be kept confidential and secure, and that it will only be used for the purposes identified herein. I further understand that I am personally responsible for the confidentiality and security of my personal information forwarded by email. This authorization may be terminated at any time upon written notice by me. In addition, if my eligibility for plan coverage ends, this direct deposit agreement will be automatically cancelled.

Date _________________________________     Signature of Plan Member __________________________________________________________________

UFCW Trusteed Dental Fund Ontario
110-61 International Blvd., Toronto, ON M9W 6K4

Fax: (416) 674-1525

Direct Deposit Application Ontario Dental 2019

©2012-2019 United Food and Commercial Workers Trusteed Dental Plan - Ontario
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