Health Savings Account (HSA) Enrollment Form

 

To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver’s license or other identifying documents.

ELIGIBILITY REQUIREMENTS:

To qualify for a Health Savings Account (HSA), the account holder must meet all of these requirements:

  • You are covered by a High Deductible Health Plan (HDHP)
  • You are not covered by a health plan, other than a HDHP, which provides any of the same benefits as the HDHP
  • You are not enrolled in Medicare
  • You cannot be claimed as a dependent on someone else’s tax return.

If any of the above requirements are not satisfied, you are not eligible to establish an HSA. By completing and submitting this Application, you affirm your eligibility to establish an HSA.

Eligibility Requirements for Rollover of Existing Health Savings Account (HSA):

If you have a Health Savings Account already established, but are no longer qualified to establish a new HSA under the requirements listed above, you may still open an HSA for the purposes of rolling over your existing HSA to a new financial institution. In this circumstance, you may use the funds already in the HSA, but cannot contribute until you are again eligible according to the above requirements.

RULES AND CONDITIONS APPLICABLE TO HEALTH SAVINGS ACCOUNTS:

General Information: An HSA is a trust or custodial account which is created exclusively for the benefit of the HSA holder, and which is generally used to pay qualifying medical expenses. If you are eligible, you or your employer can make contributions to your HSA. Qualifying distributions from your HSA are tax-free.

Definitions: High Deductible Health Plan (HDHP) generally means, as defined in Internal Revenue Code Section 223(c)(2), a health plan which satisfies the following requirements regarding deductibles and expenses for tax year 2013:

  • For single coverage, the deductible must be at least $1,200, with out-of-pocket expenses not exceeding $6,050.
  • For family coverage, the deductible must be at least $2,400, with out-of-pocket expenses not exceeding $12,100.
  • The maximum contribution amount for 2013 is $3,250 for self-only coverage, and $6,450 for family coverage.

Other rules and conditions may apply. Upon receipt and acceptance of this Application, we will send you documents and disclosures for your review and signature. Your signature will acknowledge your acceptance of these terms and your qualification for an HSA.

PERSONAL INFORMATION:

First Name:
MI:
Last Name:
Residential Address (no P.O. Box):
City:
State:
Zip: -
Mailing Address
(Complete if different from Residential Address):
Mailing City:
Mailing State:
Mailing Zip: -
Email:
Home Phone - -
Employer:
Work Phone: - -  Ext:
Social Security Number or Personal Tax Identification Number: - -
Mother's Maiden Name:
Date of Birth (mm/dd/yyyy): / /
Form of Identification:
  • Driver's License
  • State ID
  • Passport
ID Number:
ID Issue Date (mm/dd/yyyy): / /
ID Expiration Date (mm/dd/yyyy): / /
ID Country of Issue:
ID State of Issue:
 
If applicable, please specify Permanent Resident (Green) Card information below:
Permanent Resident (Green) Card Number:
Expiration Date (mm/dd/yyyy): / /
 

INSURANCE PLAN TYPE:

My Insurance Plan (Check One): Covers myself only Covers other family members in addition to me
 

POWER OF ATTORNEY (POA):

Designate a POA?: Yes No

Please note that adding a Power of Attorney individual to your HSA as a signer does not legally set up the Power of Attorney authority for that person. To set up a Power of Attorney document, please see your legal advisor. It is recommended that you also send us a copy of your legal Power of Attorney document to keep on file. The person acting as Power of Attorney for you may be asked for a copy of the legal document when conducting transactions on your behalf.

 

DESIGNATION OF BENEFICIARIES:

The funds remaining in the HSA at the death of the Holder shall be paid in the percentages indicated below (or in equal shares if no percentages are provided) to the Primary Beneficiaries who survive the Holder. If the Primary Beneficiary predeceases Holder, the interest of a Primary Beneficiary shall terminate and the percentage share of any surviving Primary Beneficiary(ies) shall increase on a pro-rata basis. If no Primary Beneficiary survives Holder, the payment shall be paid in the percentages indicated below (or in equal shares if no percentages are provided) to the Secondary Beneficiaries who survive Holder. If a Secondary Beneficiary predeceases Holder, the interest of the Secondary Beneficiary shall terminate and the percentage share of any surviving Secondary Beneficiary(ies) shall increase on a pro-rata basis. If Holder’s spouse receives the HSA as a result of being named as Beneficiary, Holder’s spouse may choose to continue the HSA in his or her name by providing a written election to the Trustee.

For any non-spouse Beneficiary, the HSA terminates as of Holder’s date of death and becomes payable. If no Beneficiaries are named in this Beneficiary Designation or if all of the named Beneficiaries predecease Holder, the HSA will be paid to Holder’s estate. Holder may change the Beneficiary Designation by filing a new Beneficiary Designation in written form acceptable to the Trustee prior to Holder’s death. Holder understands that in certain states, Holder’s spouses consent may be necessary if Holder wishes to name a person other than, or in addition to, Holder’s spouse as Beneficiary, and that Holder should consult with an attorney before making such a Beneficiary Designation.

By making the foregoing Beneficiary Designation, Holder represents and warrants to the Trustee that said Beneficiary Designation satisfies all legal requirements under applicable law and, on behalf of Holder, Holder’s heirs and Holder’s estate, Holder hereby indemnifies and holds the Trustee harmless from and against any and all claims, damages, liabilities, and costs (including attorney’s fees) arising as a result of the Trustee’s payment of Holder’s HSA in accordance with the foregoing Beneficiary Designation.

Designate Beneficiary #1?: Yes No
Designate Beneficiary #2?: Yes No
Designate Beneficiary #3?: Yes No
 

SPOUSAL CONSENT:

This section should be reviewed if either the trust or the residence of the Account Holder is located in a community or marital property state, and the Account Holder is married. Due to important tax consequences of giving up one’s community property interest, individual’s signing the Spousal Consent form should consult with a competent legal or tax advisor.

  • I am not married: I understand that if I become married in the future, I must complete a new Designation of Beneficiary form.
  • I am married: I understand that if I chose to designate a primary beneficiary other than my spouse, my spouse must sign the Spousal Consent on the Beneficiary Designation Form I will receive in my welcome package.

PRINT AND SUBMIT:

We recommend that you print this page for your records before submitting your application.