Business Pre-Authorized Debit Agreement Form

Part A: Planholder Identification

Part B: Pre-Authorized Debit (PAD) Information

1. The intent of this agreement is to facilitate the online submission of health benefit claims by the employees of the Planholder identified in Part A through the use of a Business PAD with Direct Reimbursement Associates Ltd (DRAltd). DRAltd will debit the business bank account of the Planholder for the cost of processing the health benefit claims submitted by the planholder’s employees upon adjudication of their claims.
2. The authorization provided by this PAD will allow initial and subsequent claims to be submitted online or otherwise, and health benefit plan payment transactions to be conducted until such time as this authorization is revoked in writing by the Planholder.
3. For each PAD transaction with the Planholder, DRAltd will debit the bank account identified in Part C. Since the timing of the debits will be sporadic, the launch of each transaction will be specifically initiated by the Planholder through clicking the “Submit Claim” button on the DRAltd website page specified for Online Claim Submissions or upon receipt of a claim by DRAltd submitted by a Covered Employee. By launching an online claim submission or allowing the submission of a claim by a Covered Employee, the Planholder will be concurrently authorizing a PAD withdrawal transaction from the identified bank account. It will be the responsibility of the Planholder to ensure the bank account to be debited has been correctly communicated to DRAltd. Furthermore, it will be the responsibility of the Planholder to ensure sufficient funds are available in the account at the time the health benefit claim submission is initiated.
4. The initial and subsequent PAD transactions will be executed against the same bank account until such time as the Planholder notifies DRAltd of any change of bank account.
5. The amount of each debit will be variable depending on the adjudicated amount of the claim submitted. Adjudication by DRAltd and processing of the claim will occur within 5 business days of its receipt by DRAltd. Upon adjudication of the claim by DRAltd, the PAD will be executed for the adjudicated amount. The Planholder agrees to waive notification of the adjudicated amount of the PAD before it is activated.
6. This PAD only applies to the method of payment between the Planholder and DRAltd. This agreement and any termination of this agreement has no effect, whatsoever, with respect to the contract of services between the Planholder and Direct Reimbursement Associates Ltd.

Part C: Bank Information

A VOID cheque or approved bank branch validation form must be attached with this agreement to verify the Planholder bank account information. This form and bank information can be submitted in advance or at the time of submission of the first health benefit claim. DRAltd will retain the bank account information in its secure files so that it is only required once.

Part D: Signature & Authorization

1. By signing this form the Planholder authorizes DRAltd to debit the account held at the financial institution indicated in Part C of this agreement the amounts presented during the online employee health benefit claim submission or other claim submission process. The Planholder agrees that the payments shall be made by electronic withdrawals as described in this agreement or in such other manner as DRAltd may determine. The Planholder understands that the branch of the financial institution at which the account is held is not required to verify that the payment is drawn in accordance with this authorization.
2. The Planholder agrees that the information on this form will be shared with the financial institution insofar as the disclosure of this information is directly related to and necessary for the proper application of the rules applicable for pre-authorized debits.
3. The Planholder confirms that all persons whose signatures are required to authorize transactions in the bank account specified in Part C have signed this agreement. If the business bank account requires “two-to-sign” authorization for transactions on the account, then a second authorized signatory must endorse this agreement where indicated.
4. The Planholder may change or cancel these instructions at any time provided that DRAltd receives at least 5 business days’ notice by FAX or mail. To obtain more information regarding the Planholder’s rights to cancel a pre-authorized debit agreement, the Planholder may consult their financial institution or visit the Canadian Payments Association website at www.cdnpay.ca
5. The Planholder has certain recourse rights if any debit does not comply with this agreement. For example, the Planholder has the right to receive reimbursement for any debit that is not authorized or is not consistent with this pre-authorized debit agreement. To obtain more information on the Planholder’s recourse rights, the Planholder may contact their financial institution or visit www.cdnpay.ca
6. DRAltd may use a third party to administer this Pre-Authorized Debit Agreement, such as Bambora of #200 – 1803 Douglas Street, Victoria, British Columbia, V8T 5C3.
7. The Planholder may contact DRAltd at Box 388, Pincher Creek, AB, T0K 1W0 or call 403-627- 1826.
8. The Planholder acknowledges and agrees that the Planholder is fully liable for any bank charges incurred if the debits cannot be made due to insufficient funds or for any other reason. The Planholder is accountable for compensation to DRAltd for such charges if incurred.
9. The Planholder has requested this application form and all other documents relating hereto to be in English. J’ai exigé que ce formulaire et tous les documents y afférant soient rédigés en anglais.

The undersigned hereby authorizes the execution of the above agreement. The Planholder’s financial institution is authorized to treat each debit as if a cheque had been issued authorizing such payment and debit.