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Coordination of Benefits

Discontinue Automatic Payment from Healthcare Reimbursement Account

Confirm Cancellation
Settings for plan year: 01/01/2006 - 12/31/2006

NOTE: Your cancellation will be effective today. It will not be backdated to the policy effective date. By clicking Confirm Cancellation, I understand that United Healthcare will no longer make automatic reimbursement payments from my health care Flexible Spending Account or Healthcare Reimbursement Account for expenses submitted to, but not payable by, my health plan.

You are electing to discontinue your Healthcare Reimbursement Account Automatic Payments.

Confirm
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Today's Date: Jun 5, 2006©2006 UnitedHealthcare