Minnesota Direct Deposit Form 3

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STATE OF MINNESOTA
PRE-TAX DIRECT DEPOSIT FORM
You have the option to receive your MDEA, DCEA, HRA and/or TEA reimbursements by direct deposit to your financial
institution. (If you received reimbursements via direct deposit last year, you do not need to complete this form.)
How does direct deposit work?
When using direct deposit, your reimbursement will be deposited into your account on the scheduled reimbursement date.
Whether you are on vacation, sick, or traveling out of town, your reimbursements will automatically be deposited into the
specified account and available for your use.
How will I know the amount that has been deposited?
You will receive a statement with a voided check showing the amount deposited in your bank account.
What do I need to do in order to sign up?
Complete the information below and return it to Eide Bailly Employee Benefits. You may also enter your banking information
by logging into the secure Consumer Portal at www.eidebaillybenefits.com. Direct deposits will begin with your next
scheduled reimbursement after this form has been completed, received and processed by Eide Bailly. The direct deposit will
remain in effect until you rescind or change the authorization in writing.
What if I want my deposit made to my savings account?
Ask your bank for the bank routing number and your savings account number and provide the information below.
Yes, I would like to receive my Pre-Tax Benefit reimbursements by direct deposit
Employer Name:
State Employee ID Number: _____ _____ _____ _____ _____ _____ _____ _____
First Name:
MI:
Last Name:
Home Address:
City:
State:
Daytime Phone: (
Zip:
)
FOR DIRECT DEPOSIT TO:
BANK NAME ________________________________________________________
Checking Account:
Bank Routing Number _______________________________
Checking Account Number __________________________ OR
Savings Account:
Bank Routing Number:
Savings Account Number:
By signing this form I agree to the accuracy of its contents and request to have any further deposits posted to the
above described bank account.
Employee Signature
Rev: 06/2012
**Don't forget to sign and date before sending in**
Date
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SAVE
Eide Bailly Employee Benefits  U.S. Bancorp Center  800 Nicollet Mall, Suite 1350  Minneapolis, Minnesota 55402-7033
612-253-6633 ♦ 800-300-1672 Fax 612-253-6622 www.eidebaillybenefits.com/som
Minnesota Management & Budget
NOTICE OF COLLECTION OF PRIVATE DATA
Minnesota Management & Budget administers the State Employee Group Insurance Program (SEGIP). This notice explains why we may
request information (data) about you, your dependents and beneficiaries, how we will use it, who will see it, and your obligation to
provide that information.
What information will we use?
We will use the information you provide us at this time, as well as information you have previously provided us about yourself, your
dependent(s), and/or your beneficiary. If you provide any information about yourself or your dependent or beneficiary that is not
necessary, we will not use it for any purpose.
SEMA4, the information system used to administer employee benefits, contains required information fields that may not be necessary for
us to process your request. We do not need the gender or marital status for your beneficiary designation, so you may enter “unknown” in
these fields. We only need your dependent’s date of death to process a death benefit claim or to discontinue the dependent’s coverage due
to his or her death. Student status and disability status are needed only to determine eligibility for insurance continuation for your
dependent. We only need your dependent’s social security number to offer insurance continuation or process a death benefit.
Why we ask you for this information?
We ask for this information to process your request to add or change coverage for yourself, your dependent or a beneficiary. The
requested information helps us to determine eligibility, to identify you and your dependents and beneficiaries, and to contact you or your
dependents and beneficiaries. We use the information so that we can successfully administer SEGIP, including analyzing unidentifiable
aggregate data to develop new programs and ensure current programs are effectively and efficiently meeting member needs. We may ask
for information about you that we have already collected, including all or part of your social security number, in order to ensure we are
matching you to the correct change request or other insurance benefit transaction.
Do you have to answer the questions we ask?
You are not legally required to provide any of the information requested.
What will happen if you do not answer the questions we ask?
If you do not answer these questions, the insurance benefit transaction you requested for you or your dependent or other insurance benefit
transaction may be delayed or denied.
Who else may see this information about you and your dependents and beneficiaries?
We may give information about you and your dependents and beneficiaries to the insurance carrier you have chosen, SEGIP’s
representatives, vendors, and actuary, the Legislative Auditor, the Department of Health, any law enforcement agency or other agency
with the legal authority to the information, and anyone authorized by a court order. In addition, the parents of a minor may see
information on the minor unless there is a law, court order, or other legally binding instrument that blocks the parent from that
information. We can use or relates this information only as stated in this notice unless you give your written consent to authorize release
of the information to another person/entity, or if Congress or the Minnesota Legislature passes a law allowing or requiring us to release
the information or to use it for another purpose.
We ask for this information to process your request to add or change coverage for yourself, your dependent or beneficiary. The requested
information helps us to determine eligibility, identify you and your dependents and beneficiaries, and contact you or your dependents and
beneficiaries. We use the information so that we can successfully administer SEGIP, including using unidentifiable, aggregate data to
develop new programs and ensure current programs effectively and efficiently meet member needs. We can use or release this
information only as stated in this notice unless you give us your written permission to release the information or to use it for another
purpose.
You are not legally required to provide us any of this information and you may refuse to provide the information. However, if you do not
provide us the requested information, the insurance transaction you requested for you or your dependent or other insurance benefit
transaction may be delayed or denied.
We may give information about you and your dependents and beneficiaries to the insurance carrier you have chosen, SEGIP’s
representatives, vendors, and actuary, the Legislative Auditor, the Department of Health, any law enforcement agency or other agency
with the legal authority to the information, and anyone authorized by a court order. In addition, the parents of a minor may see
information on the minor unless there is a law, court order, or other legally binding instrument that blocks the parent from that
information. This information may also be used or released if Congress or the Minnesota Legislature passes a law allowing or requiring us
to release the information or to use it for another purpose.
Rev: 06/2012
Eide Bailly Employee Benefits  U.S. Bancorp Center  800 Nicollet Mall, Suite 1350  Minneapolis, Minnesota 55402-7033
612-253-6633 ♦ 800-300-1672 Fax 612-253-6622 www.eidebaillybenefits.com/som