By signing below, I agree to allow NeuBridg, Inc. and my Employer to act as my agent to submit my application for the Lifestyle Savings Account (“LSA”) Payment Card (“Card” or “LSA Card”) to the issuing Financial Institution of the Card, and to the Terms and Conditions governing my use of the Card at the time I receive my Card. I understand, authorize, and consent to the Lifestyles Savings Account benefit plan and direct the net proceeds to be deposited on my LSA Card. I further consent to accepting electronic wage statements rather than paper. I am responsible for reviewing the applicable NeuBridg Fee Schedule for applicable fees. I understand that this authorization replaces any previous authorization relating to NeuBridg, Inc. LSA or my Employer’s payment to me, and unless terminated by NeuBridg, Inc., my Employer or the issuing Financial Institution, this authorization will remain in full force and effect until NeuBridg, Inc. has received written notification from me of its termination in such time as to afford it a reasonable opportunity to act, or I have terminated the Card as provided in the Terms and Conditions I received with the Card. I agree to review all the documents provided by the issuing Card company upon issuance of the Card. Upon approval of my application for the Card, I hereby authorize NeuBridg, Inc. and my Employer to deposit the net LSA benefit payments due to me to my LSA Card and perform the following actions or corrective actions related to my payment Card: 1) Deduct the initial issuance fee from my NeuBridg, Inc. account (if applicable); 2) Correct any funding errors made by NeuBridg, Inc. or my Employer to which I am not entitled by submitting a correcting debit to my Card account through ACH or directly to my Card account; 3) At my request, submit a request for a change in my pay Card account status to lost or stolen (or effectuate a change in the employee’s account status to lost or stolen); or At my request, transfer funds to a newly issued Card by NeuBridg.This Consent only allows my Employer to access the Cardholder activity details on my Payment Card with my written Consent.
The USA PATRIOT Act is a federal law that requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. You will be asked to provide your name, a valid physical U.S. street address, a telephone number, a date of birth, and other information that will allow us to identify you. You may also be asked to provide documentation as proof of identification. I acknowledge and agree that this authorization may be rejected or discontinued by the issuing Financial Institution at any time. After exhausting all opportunities to provide the applicant a Card, if the applicant is ultimately denied receipt of the Card, NeuBridg will provide eligible LSA deposits to the employee by check, sent to the employers corporate address.