Electronic Funding Authorization

Company Name
Contact Name / E-mail
Title / Phone / ( ) -

Action: Initiate ACH Change ACH information

We hereby authorize Premera Blue Cross Blue Shield of Alaska (Premera) or its designee to initiate debit and/or credit entries to our bank account indicated below and, if applicable, to debit or credit the same to such account related to the funding of and/or claims payments from the funding account(s) administered by Premera on our behalf. We acknowledge that the origination of Automated Clearing House (ACH) transactions to our account must comply with applicable law.

Bank Name /
Bank Routing Number

(e.g., nine-digit ABA number)

Tip Your bank may have a separate routing number for

ACH transactions. Please verify the routing number

with your financial institution to prevent delays.

Bank Account Number

Type of Account (please check one) Checking Savings

Bank Account Name

(e.g., general checking account, operating account)

This authorization is to remain in full force and in effect until Premera has received written notification from us of its termination in such time and in such manner as to afford Premera and our bank a reasonable
opportunity to act on it. We understand that changes to any information on this form must be submitted by the close of business Monday to ensure that these changes will take effect by the following week.

The undersigned is authorized to sign this funding authorization on behalf of the company.

Signature / X / Date
Title

Note Premera or its designee may run a test of the ACH process (i.e., pre note) to be sure it is working properly.

You may see a transaction on the account with a $0 charge.

Return completed and signed form to your Premera Sales Representative, or mail form to
3800 Centerpoint Drive, Suite 940, Anchorage, AK 99503. Call 907-258-5065 if you have questions.

For Premera Use Only: Group ID Number ______Subgroup(s) ______
£ FACETS HRA — GSU TSS QA&A mailbox £ CYC PFA — CYC £ NON-HRA — FINANCE

An Independent Licensee of the Blue Cross Blue Shield Association

015889 (11-2016)