I understand that I am requesting a modification to the financial institution information on file with NeuBridg, Inc. and its Third Party Administrator (hereinafter “NeuBridg” I hereby grant and instruct NeuBridg to perform the request as shown above to my account to reflect the above account number, routing number and/or account type. I, further authorize NeuBridg to utilize the above account information for all eligible deposits for all my NeuBridg accounts.
I understand this requested modification will be effective as of the indicated date, provided NeuBridg is in receipt of said form prior to the effective date on the form and shall remain in effect until it is modified or terminated by the submission of a subsequent Direct Deposit Entry Form. If no effective date is provided, the effective date shall be the date the form is received by NeuBridg. In the case of an account discrepancy, the last Direct Deposit Entry Form received by NeuBridg shall be the controlling form. I hereby grant my employer and/or NeuBridg ample time to affect the change and shall hold my employer, NeuBridg, or any other parties harmless should a distribution be deposited into a previously authorized account or a check sent to an incorrect address on file.
By signing/electronically signing this document, I authorize, NeuBridg,Inc., Midwest Group Benefits, Inc. and the financial institution listed to initiate electronic credit entries, and if necessary, debit entries and adjustments for any credit entries in error to my account.