Direct Deposit Enrollment

Direct Deposit Enrollment

Company:
Employee Name:
Participant Id:		xxxxxxxxxx
Email:
Phone:		xxx-xxx-xxxx

Please note: You will receive e-mails from donotrespond@askallegiance.com, Please save to your address book to ensure proper delivery.

If you are not currently using direct deposit:

Please complete this form.
Go to www.allegianceflexadvantage.com and establish an account password.

If you are already using direct deposit:

There is no need to sign up again, unless you have a new checking account..
Please access your online account and verify that your e-mail address is correct.

You will not receive an explanation of benefits (EOB) through the mail. When your e-mail address is included above, you will receive an e-mail notification each time a flex claim is processed. Your EOB is available by clicking on Claims History.

If you are unable to complete this information at this time please print the Direct Depost Enrollment Form, complete and submit to Allegiance later.

Example of Routing and Account Number Locations


Routing #:		Re-enter Routing #:
Account #:		Re-enter Account #:

Attach Scan of Check (Optional) Accepted File Types: tif, jpg, pdf (Size Limit 3 MB) Select EACH File with Browse, then click Add

Total Files Added: 0

I hereby authorize Allegiance Benefit Plan Management, Inc. to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my account as indicated below and depository named below, hereinafter called BANK, to credit and/or debit the same such account. This authority is to remain in full force and effect until Allegiance Benefit Plan Management, Inc. has received written notification from me of its termination in such time and manner as to afford Allegiance Benefit Plan Management, Inc. and the BANK a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer-sponsored flexible spending plan.

By clicking this box, I hereby certify that I am the person whose name appears above, and that my name as it appears above is intended for purposes of this direct deposit form to be my genuine signature and acknowledgement of this document.

Comments/Address Change: