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2806 Garfield, P.O. Box 4346, Missoula, MT 59806-4346 Phone: [PHONE REDACTED] I Fax: [PHONE REDACTED] I www.askllegiance.com FLEX ENROLLMENT DIRECT DEPOSIT FORM If you are not currently using direct deposit: • Please complete this form and fax to Allegiance (1-[PHONE REDACTED]). • Go to www.askallegiance.com and establish an account password. If you are already using direct deposit: • There is no need to sign up again, unless you have a new checking account. • Please access your online account and verify that your e-mail address is correct. You will not receive an explanation of benefits (EOB) through the mail. When your e-mail address is included below, you will receive an e-mail notification each time a flex claim is processed. Your EOB is available by clicking on Claims History. Employer Name: Name: Participant ID: Please note: You will receive e-mails from [EMAIL REDACTED]. Please save to your address book to ensure proper delivery. I hereby authorize Allegiance Benefit Plan Management, Inc. to initiate credit entries and, if necessary, debit entries and adjustments for any credit entries in error to my account as indicated below and depository named below, hereinafter called BANK, to credit and/or debit the same such account. This authority is to remain in full force and effect until Allegiance Benefit Plan Management, Inc. has received written notification from me or its termination in such time and manner as to afford Allegiance Benefit Plan Management, Inc. and the BANK a reasonable opportunity to act on it. I understand this authorization is for reimbursements from my employer-sponsored flexible spending plan. Signed: Date: ATTACH A VOIDED PERSONAL CHECK HERE. E-mail address (please print): City of Missoula SIGN