EDIS Employer Banking Form

EDIS Client Record * Required

WCA Employer ID

EDIS Benefit Account Funding Form

EDIS will no longer hold employer or employee funds. This is a significant improvement from our prior banking rules were employers were required to make a prefunded deposit. Instead, we pull funds directly from the employer’s designated bank account only as claims are incurred. This structure eliminates the need for prefunding, and any unused balances remain with the employer.

Employer Name

Current Claim Reimbursement Method(s) * Required

Debit Card

Check

Direct Deposit

___ Banking Information

Please provide EDIS with the designated employer bank account in which funds will be pulled from if/when a ___ member incurs a valid claim eligible for reimbursement under their EDIS benefit account.

Bank Account Type * Required

Checking Account

Savings Account

Please ensure the account is a transactional account that allows for ACH pulls and pushes.

Bank Name * Required

Bank Routing Number

* Required

Bank Account Number

* Required

EDIS Banking and Reimbursement Terms and Conditions * Required

Your bank should be provided with the following banking information to ensure EDIS and our banking partner is placed on the “approved” list. This is particularly important when employers offer employees the ability to be reimbursed via direct deposit and/or employees are issued debit cards.

Transactions often take place daily. To ensure no disruption with service, EDIS' banking partner needs to be able to draft funds the same day in which the transaction takes place. Please make sure you are aware of any bank withdraw limits that may impact your activity. This is particularly important should there be any positive pay/fraud features enabled on the account which usually has strict – often short – deadlines to approve drafts.

SUBMITTING BANK: BMO HARRIS BANK

BANK COMPANY NAME (ACCOUNT NAME): Med-I-Bank or MBI

COMPANY ID (Daily POS Settlements): 1383261866

COMPANY ID (ACH RESUBMITS): W383261866

COMPANY ID (MANUALS): 3W38326186

ROUTING NUMBER: 071000288

To ensure that the account is valid, the appropriate filters and approval process have been put in place, and that EDIS has the correct account/routing information on file - a refundable $1.00 pre-note will be drafted before the platform is rolled out to the employees.

I hereby certify that the information provided throughout this form to be correct and true to the best of my ability.

Debit Card Reimbursement Verification

Default debit card shipping mailing address: * Required

Employer Address

Employee Mailing Address

EDIS will mail all employee and dependent debit cards to the employer address on file unless specified differently here.

Check Reimbursement Verification

For check reimbursements, please provide the starting check number EDIS should be using

If left blank, EDIS will begin starting check # with 202571

Do you want to provide your employer signature?

Yes

If yes, you will be required to provide EDIS with an employer signature to be used and included on the physical check reimbursements issued by EDIS to employees and/or providers.

EDIS will process and produce claim checks from the employer bank account provided on this form, and only the employer can sign them. EDIS batches and mails checks ready to be signed to the employer every two weeks.

Authorized Employer Signature * Required

E-Signature Field

Clear

The signature provided above will be included on the physical check reimbursements issued by EDIS to employees and/or providers. Please do not type your name nor provide an electronic timestamp as your signature.

Check & Direct Deposit Reimbursement Schedule

EDIS reimburses employees for eligible and approved manual claims (via check or direct deposit) on a daily basis. However, some employers prefer a more structured reimbursement timeline. To accommodate this, EDIS now offers the option to issue manual reimbursements according to a defined schedule—such as weekly, semi-monthly, or monthly frequency. Debit card transactions can not be set up on a schedule. Debit card funds need to be available at all times.

Confirm Reimbursement Schedule: * Required

Daily (Default)

Weekly

Semi-Monthly

Monthly

Specify the day of week reimbursements should be issued: * Required

I.e.) Friday

Specify the two days each month payments should be issued: * Required

I.e. ) 1st and 15th of each month

Specify the day each month payments should be issued: * Required

I.e.) 15th of each month

Main Banking Contact Name * Required

Main Banking Contact Email * Required

Add Additional Banking Contacts? * Required

Yes

Add Additional Bank Contact

Additional Banking Contacts

View

Add Entry

Add Contact

Additional Banking Contacts *

Required

First Name

Required

Last Name

Email * Required

Banking Submitted

Yes

Plan Funding Source

Employer Account

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