TO BE COMPLETED IF YOU SELECT PLAN 2: And 1) Am not participating in an FSA OR 2) Am choosing to participate in the Post Deductible FSA
HEALTH SAVINGS ACCOUNT (HSA) ENROLLMENT FORM Employee Name: ______________________________ SS#: ________________________________ Address: _____________________________________________________________________________ City: ______________________________ State: _____________________ ZIP: _________________ Phone: ____________________________ Date of Birth: _____________________
Enrollment Type: (Bi-weekly Payroll Frequency – 26 pay periods) Open Enrollment for January 1 New Hire: Effective Date _________________ First Payroll Date ________________________ Election Amount: By my signature below, I authorize my Employer to make pre-tax salary reduction contributions on my behalf to my Health Savings Account for the Plan year: I am enrolled in Plan 2 and do not wish to contribute to a Health Savings Account. I am enrolling in Plan 2 and would like to transition my Flexible Spending Account (FSA) to a post deductible FSA. I would like to contribute additional pre-tax dollars to my Health Savings Account. Pre-Tax Dollars Per Pay Period: $_____________ 2021 IRS MAX Contributions: Individual $3,600
Family $7,200
TERMS & CONDITIONS:
I understand in order to contribute to a Health Savings Account I must be covered by my Employer’s Group Health Plan which is a high deductible health plan (HDHP) under code 223(c) (2) and not be covered under any other health coverage that is not a HDHP or permitted non-HDHP insurance or coverage. If I am married, my spouse does not have any non-HDHP family coverage. I am not entitled to Medicare benefits. I understand my employer may make my payroll contributions to my HSA account and any employer contributions, if applicable; however, it is my responsibility to make sure I do not go over the IRS maximum contribution amount listed above. I understand that if I need to make a change in my contributions, I must do so prior to the start of the next month and complete the change form. I understand that I am the owner of my HSA account and that I am the record keeper of my HSA account should I be audited by the IRS. I certify that the information provided by me on this Enrollment form is accurate.
Signature of Employee
Date