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Member s Signature Date Return completed form to PEARL CARROLL ASSOCIATES CLAIMS DEPARTMENT 12 CORNELL ROAD LATHAM NY 12110 Forms may be faxed to 518-640-8105 or emailed to CUSTOMERCARE PEARLCARROLL.COM G11628 CSEA EFT 05/17. I understand that any deposit made to an inactive account will be returned to the Plan Administrator and reissued as a manual check. CSEA POLICY NUMBER G-11628-0 To enroll in the Electronic Funds Transfer EFT payment service please provide the following information....

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