Fill and Sign the Progress Report of Students Work Raven Homeschool Form

Recurring Reimbursement Election Aetna Global Benefits® Your Aetna Global Benefits (AGB) plan of benefits includes the option of claim reimbursements in a variety of currencies and disbursement methods, as available, through an arrangement with Citibank, N.A. (New York). This form is required to create or replace a recurring reimbursement election established to receive benefit reimbursements in a method/mode other than U.S. Dollar checks. Recurring reimbursement elections are for employees who are requesting that their and their covered dependents’ ensuing claim payments be uniformly issued in the same currency, method, and, as applicable, to the same bank account or location. Non-U.S. currency payments can be issued via a Check, Wire, or Electronic Funds Transfer (EFT), depending on the currency classification and recipient location. The currencies are classified as primary, secondary, or tertiary and these classifications will change from time to time without notice. You may specify your preferred mode of payment on this form; however, AGB and Citibank, N.A. (New York) reserve the right to issue the benefit payment in the mode of payment which is available for the currency type, as circumstances require. Instructions - Refer to this page when completing the form. • • • • Please print legibly and complete all of the items on this form to establish/modify a recurring reimbursement election. We cannot and will not process forms with missing, illegible or inaccurate information. In the event of an incomplete or illegible form, benefit payments will be made via a check in U.S. dollars. Submit this completed form by AT&T Global Toll Free Fax to (800) 475-8751 or mail this completed form to: Aetna Global Benefits, P.O. Box 30258, Tampa, FL, 33630-3258, U.S.A. Contract Information 1. Group Control-Suffix-Account: Include the Group Control, Suffix and Account numbers for the AGB contract in which you and your dependents were enrolled in when the claim was incurred. (Refer to your ID Card for this GRP information.) 2. Employee Name: Enter the first name, middle initial and last name of the individual who will be receiving the claim reimbursement(s). As used, herein, the term “Employee” shall be defined to include the Participant through which eligibility under this Plan has been derived. Employee Information 3. Employee Social Security/I.D. Number: Enter the identification number under which the employee and his/her dependents are enrolled. This will be the employee’s Social Security Number (if applicable) or an identification number that has been assigned by AGB that may be found on your AGB Identification card. 4. Employee Telephone: Enter the Employee’s telephone number. Please include country or city codes if required. 5. Employee Address: Enter the Employee’s Street, City, State, Country, Postal and Email Address information. 6. If the Employee Is Not the Bank AccountHolder: If wire payments are being requested for transfer into a bank account that is under a different name than the Employee, Provide the bank accountholder’s telephone number. Bank Information 7. Bank Name: Enter the name of the bank or financial institution into which benefit payment(s) will be deposited. You shall notify AGB in writing of any changes to this information and note these transactions as a change in Section #13. Please be aware that it is the Employee’s responsibility to appropriately communicate these (Contact your changes, as the Employee will be responsible for any non-returned benefit payments distributed to your bank to complete erroneously indicated account. / confirm the 8. Bank Identification Code: Enter the bank “ID Code” (Routing Number) by which the bank can be identified for information in this funds transfers. The covered member should contact their bank(s) to verify this number. Please indicate if this section.) code is a S.W.I.F.T./BIC, CHIPS UID, Federal ABA, Bank Sort identification code or IBAN. 9. Bank Account Number: Enter the bank account number into which benefit payments should be transferred. 10. Bank Accountholder’s Name: Enter the name of the bank accountholder into which benefit payments should be transferred. Enter this name as it appears on the Banking Statement. 11. Bank Address: Provide the phone number and address of the bank into which benefit payments are being deposited. Payment Information 12. Payment Information: Check the box that indicates your preferred method of payment and specify a currency. 13. Reimbursement Election Request: Check the box to indicate if this request is to either establish an initial Recurring recurring reimbursement election, to replace a previously requested recurring reimbursement selection with the Reimbursement newly supplied information, or to eliminate an existing reimbursement selection and revert to payment via US Election dollar checks. Authorization GR-67827 (9-06) 14. Signature: Both the Covered Member and the Bank Accountholder’s (if different than the Covered Member) signature(s) and date(s) are required to authorize U.S. Dollar Wires and Non-U.S. Currency Claim payments. A-POD Page 1 of 2 Aetna Global Benefits® Recurring Reimbursement Election Contract Information 1. Group Control-Suffix-Account 2. Employee Name Employee Information Bank Information 3. Employee Social Security / I.D. Number 7. 4. Employee Telephone Number 8a. Bank Identification Code 5a. Employee Street Address Bank Name 5b. Employee City 8b. Bank ID Code Type: S.W.I.F.T./BIC CHIPS UID 9. Bank Account Number 5c. Employee State / Country 10. Bank Account Holder’s Name (Exactly as it is listed with the Bank.) 5d. Employee Zip / Postal Code 11a. Bank Street Address 5e. Employee Email Address 11b. Bank City 6. 11c. Bank State / Country If the Bank AccountHolder is Different than the Employee, Provide the Bank AccountHolder’s Telephone Number. Federal ABA IBAN Bank Sort ID 11d. Bank Zip / Postal Code 11e. Bank Phone Number (Including Country Code) 12. Payment Information Check the box that indicates your preferred method of payment. If other than a U.S. Dollar wire, indicate the currency in which reimbursement is desired. AGB can wire or Electronic Funds Transfer (EFT) reimbursements to your bank at no cost. However, we encourage you to check with your bank to determine the fee your bank may charge you for these transactions. Electronic Funds Available as follows: Australia – AUD (Dollar) Germany – Euro New Zealand – NZD (Dollar) Transfer (EFT) Austria – Euro Great Britain - GBP (Pound) Norway - NOK (Krone) Belgium – Euro Greece – Euro Portugal – Euro Canada - CAD (Dollar) Hong Kong – HKD (Dollar) Singapore SGD (Dollar) Denmark - DKK (Krone) Ireland – Euro Spain – Euro Finland – Euro Italy – Euro Sweden - SEK (Krona) France – Euro Netherlands – Euro United States - US$ (Dollar) Wire U.S. Dollars Wire (specify currency) (Click arrows to display available list(s) of currencies to select. If not listed, indicate “Other and the requested Country/Currency in the space provided above.) Check (specify currency) (Click arrows to display available list(s) of currencies to select. If not listed, indicate “Other and the requested Country/Currency in the space provided above.) 13. Recurring Reimbursement Election Check the box that indicates your preferred recurring reimbursement election. (Based on the information listed in Boxes #7 to #12.) This is an Initial Request for the establishment of a recurring reimbursement election. Please use this information for the delivery of all future reimbursements or until a change in reimbursement elections is made. This is a Change Request. Please replace my previously established recurring reimbursement election with the information provided above or attached. This is a Termination Request. Please eliminate my previously established recurring reimbursement election and revert to claim reimbursement via US dollar check. 14. Authorization ( Signature and Date Required) I, (Employee’s Name) hereby authorize Aetna Life & Casualty (Bermuda), Ltd., Aetna Life Insurance Company, and any of their affiliated companies (“Aetna”) and/or its dedicated Agents to make payments of any benefits payable to me and/or my dependents, by crediting such payments to my account at the bank or financial institution named above. I agree to notify Aetna in writing of any change relating to the information provided on this form or of a withdrawal of this authorization. I agree that if, for any reason unearned benefit payments are deposited into my account, I will immediately repay the full amount of any such payments. I further agree that if I do not immediately repay such unearned payments, I will be personally liable for all costs of collection. These costs include reasonable attorney’s fees, incurred by Aetna and/or its dedicated Agents in the collection of such payments, together with the maximum interest or charges permitted by law. In the case of any overpayment of benefits to my account, I agree that Aetna may debit my account for such overpayment, without further authorization from me. I also acknowledge my responsibility to notify AGB in writing of any changes in the information indicated above. Employee’s Signature (Include Bank Accountholder’s Signature if Different than the Employee) Date Please Retain A Copy For Your Records GR-67827 (9-06) Coverage underwritten by Aetna Life Insurance Company and Aetna Life & Casualty (Bermuda) Ltd. Page 2 of 2