Method of Payment Form

METHOD OF PAYMENT - (Must Include Enrollment Form)

   Professional Benefit Administrators
   1130 Hurricane Shoals Road NE   Ste 2300   Lawrenceville, GA 30043
   (770)963-3939    (800)578-2082   Fax:(888)264-6975

EMPLOYEE INFORMATION

Name of Federal Employee: __________________________________________________________________
(Please Print)

Social Security Number:___________________________________________________________________

Address: ________________________________________________________________________________
Street City State Zip

CHOOSE ONE (1) METHOD OF PAYMENT BELOW AND SIGN

(1) Allotment / Payroll Deduction method of payment Check Here______

   I hereby authorize Transaction Allotment Inc. (TAI) to receive my payroll deduction into their Wachovia Account (identified by my Social Security Number),
   and indicated above in the TOTAL PAY PERIOD DEDUCTION AMOUNT. I also authorize TAI to distribute that amount as indicated above. I further
   authorize TAI to disclose my Social Security Number and other nonpublic personal information to third parties as necessary to effect and administer the
   services to be performed by TAI hereunder.. I further agree that if my employer fails to deduct and/or transmit the required payments, whether intentionally,
   inadvertently or otherwise, TAI shall have no liability whatsoever with respect thereto even though such failure results in the forfeiture of any and all insurance
   policies or contracts. I further understand that any insurance coverage will only be effective upon the date of coverage stated on the respective policy(s) and after
   premium money has been collected and applied by the insurance carrier.

   Signature of Enrollee:__________________________________________

(2) ACH / BANK DRAFT METHOD OF PAYMENT (10th of Each Month) Check Here______

   I hereby authorize Transaction Allotment Inc. (TAI) to initiate entries to my checking/savings accounts at the financial institution listed below, and if
   necessary, initiate adjustments for any transactions credited/debited in error. This authority will remain in effect until TAI is notified by me in writing
   to cancel it in such time as to afford TAI and the financial institution a reasonable opportunity to act on it.

   DEBITS ONLY: I also understand a $20.00 fee will be collected from my account on the next debit date should the previous debit be returned by the
   financial institution as Non Sufficient Funds or any other reason. IN THE EVENT OF FUTURE INCREASES IN PROVIDER CHARGES, TAI IS AUTHORIZED TO
   INCREASE THE AMOUNT(S) OF THE ABOVE DEBIT(S) BY SUCH AMOUNT UNLESS OTHERWISE NOTIFIED IN WRITING BY ME IN
   WHICH EVENT THE SUBJECT COVERAGE WILL BE TERMINATED.

FINANCIAL INSTITUTION INFORMATION:

Name of Financial Institution: ________________________________________________________________

   Address of Financial Institution:______________________________________________________________
   (Branch, City, State, & Zip)

INDICATE ONE TYPE OF ACCOUNT

(1) Checking Account #__________________________________________ (Voided Check must be attached)

- or -

(2) Savings Account # ___________________________________________ (Statement must be attached)

Bank Routing Number: ___ ___ ___ ___ ___ ___ ___ ___ ___ (Must be nine (9) digits only)

Signature of Enrollee:____________________________________________________________________

Please note: TAI (Transaction Allotment Inc.) will deduct a NON-REFUNDABLE Administrative Fee for each processed Allotment or Bank Draft

Agent (Print) ______________________________________________________ Date ________________
Rev: 01/10/06