Funds Transfer Form - Co-op Services Credit Union

FUND TRANSFER PROGRAMSECTION 1: Member Information (Print or Type)Last Name First MI Social Security NumberBusiness TelephoneHome Telephone(_ )______________ (_ )______________I certify that I have read and understand the back of this form. In signing this form, I authorizeUnited Concordia Companies, Inc. and the financial institution listed below to debit my account,According to the terms, automatically in the second week of the month of coverage.Adjusting entries to correct error(s) is also authorized.______________________________________________________SignatureDate_____________SECTION II: Account Information (Print or Type).Name: Co-op Services Credit UnionAddress: City State Zip29550 Five Mile Rd. Livonia MI 48154Transit/Routing Number Account Type Account Number272477694 Checking OnlySECTION III: Additional InformationFAX Completed Information to:734/466-6154Attn: Beverly Outland2013

COMPLETING YOUR APPLICATION FOR THE UCCI FUND TRANSFER PROGRAMThis information included in the UCCI Fund Transfer Program application will be used toprocess payment data from UCCI to Co-Op Services Credit Union. Your application forenrollment will not be processed without this form.INSTRUCTIONS1. Please complete the form, providing information requested in all sections. Allinformation, including your Social Security Number, is required for settlement of funds.Your work and home telephone numbers are required in the event it becomes necessaryto contact you. The information you provide will be kept strictly confidential.2. Please sign the application in the area indicated. By signing the document, youauthorize your participation in the Fund Transfer Program and agree to its terms.3. Please allow up to 30 days for processing of your application. After your applicationhas been processed, you will receive confirmation, a UCCI ID card will be mailed toyour address listed on your application.4. The debit to your account will be on the Second Friday of the month of coverage. Referto open enrollment materials for information on rates, terms and conditions of the UCCIdental program.AVAILABILITY OF FUNDSCo-Op Services Credit Union will use ordinary care under NACHA guidelines for theprocessing of Fund Transfer Program transactions.Refer to your Credit Union’s availability of funds policy.Please be aware that your Credit Union may charge a fee in the event your account hasnon-sufficient funds at the time of billing. {Second Friday of the Month} If the Funds arenot available another attempt will be made to debit your account on the Fourth Friday ofthe month. If we are unable to pull funds at that time, your policy will beterminated at the first of that current month.CANCELLATIONS/CHANGESTo Add/Delete a dependent Or cancel the policy, please send written documentation toUnited Concordia At :PO Box 69423Harrisburg PA 17106-9423 717/260-7757 FaxCall United Concordia Companies, Inc. Toll Free at 1-866-357-3304 Customer Service