Get Please Fax Or Mail This Form To

Filling out the Please Fax Or Mail This Form To is essential for ensuring your flex or HRA reimbursement is directly deposited into your bank account. This guide will provide you with clear, step-by-step instructions to complete the form accurately and efficiently.

Follow the steps to complete your form correctly.

1. Press the ‘Get Form’ button to access the form and open it in your preferred document editor.
2. Begin by entering the name of your employer in the designated field.
3. Provide your daytime phone number to ensure that you can be reached if needed.
4. Fill in your name as the employee, entering your last name, first name, and middle initial.
5. Input your Social Security number in the specified section, ensuring accuracy for processing.
6. Complete your address by filling in your street address, city, state, and zip code.
7. Enter your banking information, which includes the routing number and account number for the account where you want the funds deposited.
8. Indicate whether you wish to deposit into a checking account or savings account by marking the appropriate box.
9. If necessary, you may attach a voided check for verification of your banking information. Make sure it is clear and readable.
10. Review the authorization statement, confirming your agreement for American Fidelity Assurance Company to make deposits into your account.
11. Sign and date the form in the designated areas to validate your request.
12. Once you are finished, save your changes, and choose to download, print, or share the form as needed.

Complete your document online today to ensure a smooth reimbursement process.