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ELECTRONIC PAYMENT CONSENT

Complete to change to payment by direct deposit by e-transfer

Purpose of this document is to obtain the participants consent to have claim reimbursement funds deposited directly to their personal bank account by means of bank interac e-transfer Funds will only be deposited to Canadian Banks and in form of Canadian Currency.

Identification of electronic funds recipient (if completing by hand please print)

Required Information for set-up of direct online payment by interac®e-transfer

The undersigned certifies accuracy of the above information and consents to receiving the reinbursement of all medical claims submitted to Assureflex by electronic funds transfer; namely interac® e-transfer, the undersigned may revoke or cancel the authorization at any time by notifying Assureflex: mailroom@assureflex.com

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Information collected is treated as private and confidential and is for the sole purpose of providing reimbursement of claims by interac® e-transfer. Information is never shared with any third parties electronically or by other means.

Interac® and its symbol are the registered and dually recognized trademarks of the Canadian interbank network
Assureflex Corporation® Tel. 1-519-245-3283 Toll-Free Fax: 1-855-280-3295 email: mailroom@assureflex.com
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