F00023 Retiree Medical Insurance Plan Direct Deposit of Medical Insurance Claim Payments (Aetna Only)

F00023 Retiree Medical Insurance Plan Direct Deposit of Medical Insurance Claim Payments (Aetna Only)

Instructions:

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Information on Completing the Form

1. This form is only for Aetna Members; Do Not Use for Cigna Members (MBP)

2. Direct Deposit of MIP reimbursements can only be paid into the primary pension bank account from which a retiree's RMIP premium is withdrawn. This account must be held by a US Bank/Credit Union capable of processing ACH transactions

3. Print and sign form

4. Please return this form to HR Operations via (please select one transmittal format, and submit only once):

a) Email to hroperations@worldbank.org

b) Fax +1 (202) 522-7026

c) Mail to MSN MC3-300, P.O. BOX:  1420, Landover MD 20785, USA

 

REMEMBER TO NOTIFY THE PENSION ADMINISTRATION UNIT AT 1PENSION@WORLDBANK.ORG

                   OR +1-202-458-2977 IF YOUR BANK ACCOUNT INFORMATION CHANGES

Need Help? 

If you are experiencing any issues, please contact HR Operations via email: hroperations@worldbank.org  or phone 202-473-2222 or 5220+32222.

Revision 16 Oct 2024

REMEMBER TO NOTIFY THE PENSION ADMINISTRATION UNIT AT 1PENSION@WORLDBANK.ORG
 OR +1-202-458-2977 IF YOUR BANK ACCOUNT INFORMATION CHANGES

I hereby withdraw from the Direct Deposit MIP Program. I understand that the Direct Deposit MIP Program will be started/discontinued within 60 days from the date this form is received.

Retiree Details

World Bank Group UPI*

 

Retiree Name (Last, First , MIddle)*

 

Direct Deposit MIP

Please check one box

I elect to enroll/continue my enrollment in the Direct Deposit MIP Program under which all Retiree MIP (RMIP) claim payments on behalf of myself and/or my eligible family members (not assigned to a provider) will be deposited in US Dollars directly into the primary pension bank account  that my MIP premium is deducted from (net deposit). I have confirmed that the financial institution that maintains this account is a member of the Automated Clearing House (ACH) system.  I understand the MIP claim payments will be sent through that system to my account by Electronic Funds Transfer (EFT)

I authorize the World Bank Group to provide Aetna, Inc. with the same information about my bank/credit union account that I have provided the World Bank Group Pension office.

I understand that if I change my bank/credit union account with Pension, and I am enrolled in the Direct Deposit MIP program, the new account number will automatically be provided to Aetna, Inc. after the account number has been updated which may take up to 60 days.  I further understand that all Direct Deposit of MIP claim payments are made in US dollars only.   If my bank/credit union ceases to be able to process ACH deposits, or if I change to a bank/credit union that cannot process ACH deposits, I understand that my MIP reimbursements will be paid by paper check in US dollars.

I hereby withdraw from the Direct Deposit MIP Program.  I understand that the Direct Deposit MIP Program will be started/discontinued within 60 days from the date this form is received.

Signature of Insured

Signature

Date

After filling this document, you must sign and date it before returning this document to the World Bank Group. Please ensure ALL information in the submission form is complete and accurate before printing the form. This will generate your form(s) as a PDF file. Review the file for accuracy and completeness. If there is an error, please start a new form.