Form Pm 605773 PDF Details

In today's digital age, the convenience of Electronic Fund Transfer (EFT) cannot be overstated, especially when it comes to receiving monthly benefits securely and promptly. The PM-605773 form embodies this modern necessity, serving as a crucial document for individuals looking to enroll in EFT services, amend their current details, or cancel the service entirely. It is a straightforward process that requires the completion of requested information, ensuring the absolute accuracy of personal and banking details to facilitate the seamless transfer of funds. For those receiving Survivor Income Benefits, the inclusion of the deceased insured's name, known as the "Certificate Holder," is essential. The form also mandates the submission of a voided check or a deposit slip, depending on whether the funds are directed to a checking or savings account, to confirm the authenticity and correctness of the bank account details. Moreover, signatories must understand that by authorizing EFT, they allow not only the deposit of monthly net benefits into their designated account but also permit the company to rectify any accidental deposits via direct debits. The PM-605773 form, therefore, not only simplifies the way beneficiaries receive their payments but also places a significant emphasis on accuracy, security, and personal responsibility, promising a reliable financial management tool for eligible recipients.

QuestionAnswer
Form NameForm Pm 605773
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other namesomissions, cigna electronic funds transfer authorization form, PM-605773, cigna eft enrollment form for providers

Form Preview Example

FOLLOW THESE EASY INSTRUCTIONS TO ENROLL:

1. Please complete all of the information requested whether you are enrolling for EFT service, requesting changes or canceling the service.

2. If you are receiving Survivor Income Benefits, please include the name of the deceased insured ("Certificate Holder").

3. Be sure to include a voided check (if requesting EFT to your checking account) or a deposit slip

(if requesting EFT to your savings account).

4. Sign, date and return in the envelope provided. Please allow 4 to 6 weeks to process your authorization form.

Retain a completed copy for your records.

ELECTRONIC FUND TRANSFER (EFT) AUTHORIZATION FORM

1. Please provide the following information:

Your Name:

Certificate Holder’s Name*:

Address:

City:

 

 

State:

Zip:

 

 

 

 

 

Telephone No.:

 

 

 

 

area code

(

)

 

 

 

 

 

CIGNA Policy/Account No.:

Social Security No.:

 

* Include the name of the deceased only if you are receiving Survivor Income Benefits (please disregard if you are receiving Disability Benefits).

2.

Select type of transaction:

 

 

Request to enroll

Change the following information:

 

Request to cancel

Account Number

 

 

Account Type

 

 

Financial institution

 

 

 

3.

Indicate type of account:

 

Checking account (include a blank personal check marked "void")

Savings account (include a deposit slip if available)

4. Provide the following information:

Name of Bank:

 

Branch Office:

 

 

 

 

City:

State:

 

Zip:

 

 

 

Branch Telephone No.:

 

Bank Account No.:

Bank Routing No.: (First nine digits of check code line)

5.Sign and date this authorization statement:

I authorize the Insurer of the policy/account number identified above ("Company") to deposit my monthly net benefit into the account and bank I have indicated above or such other account as the bank or any successor designates as my account. I also authorize you to debit my account for any deposits made in error. I understand that the EFT service is only available for personal accounts, not business or corporate. I also understand that the EFT service will stay in effect until I notify the company of cancellation on the EFT service authorization form. I accept the responsibility to notify the Company if there are any errors in my account and will not hold the Company liable if there are any errors or omissions in depositing benefit payments to my designated account.

Signature X

Date

 

 

 

 

 

 

 

 

 

PM-605773 REV. 10/2008

Retain a completed copy for your records.

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How to complete cigna electronic funds transfer authorization form portion 1

2. Just after the previous array of blank fields is done, go to type in the applicable details in these - Be sure to include a voided check, Sign date and return in the, Retain a completed copy for your, Indicate type of account, Checking account include a blank, Savings account include a deposit, Provide the following information, Name of Bank, Branch Office, City, State, Zip, Branch Telephone No, Bank Account No, and Bank Routing No First nine digits.

cigna electronic funds transfer authorization form conclusion process explained (part 2)

3. Through this step, review I authorize the Insurer of the, Signature X, PM Rev, Retain a completed copy for your, and Date. All of these need to be completed with greatest accuracy.

Signature X, Date, and PM Rev inside cigna electronic funds transfer authorization form

Always be very attentive while filling out Signature X and Date, because this is where a lot of people make a few mistakes.

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