Section B NEW CONTACT Information N/A

Contact or Funding Change Notification

Use this form to notify us of a change in contact information or to add a bank account for plan funding.

SECTION A – GENERAL INFORMATION

1. Employer Name:

2. Federal Tax ID Number (EIN):

3. Change Effective Date: / /

Section B – NEW CONTACT Information N/A

1. Name:

2. Direct Phone Number:

3. Email Address:

Setup/Re-enrollment 4. Type of Contact (Select all that apply): Day-to-Day Billing

5. Online Access Needed to CS Employer Portal: Yes No

6. Replacement Contact: Yes, this contact has replaced (Name): No, this is an additional contact

SECTION C – EMPLOYER SIGNATURE For officer or department leader use only; Must currently be listed as an authorized contact at the employer group.

By signing below, I approve the information obtained within this document for purpose of changing a plan contact and/or funding account.

Employer Signature Date / /

Fifth Third CDH Contact or Funding Change Notification (CN1) v4.17