HealthSavings ACCOUNT OPTIONS
PRIMARY INFORMATION
Name:
(Attach copy of Driver’s License or State Issued ID)
Street Address:
Mailing Address (if applicable) :
Social Security Number: Cell Number:
Email Address:
Type of Health Insurance Plan Coverage: q Self-Only q Family
SPOUSAL BENEFICIARY CONSENT
Community or marital property state laws may require spousal consent for a non-spouse beneficiary designation. The laws of the state in which the financial organization is domiciled, the HSA owner resides, the trust is located, the spouse resides, or this transaction is consummated should be reviewed to determine if such a requirement exists. Spousal consent for the beneficiary designation may also be required by financial organization policy.
q I Am Married. I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent via e-sign.
Spouse Cell Number for E-Sign Consent:
Spouse Email Address for E-Sign Consent:
q I Am Not Married. I understand that if I marry in the future, I must complete a new Designation of Beneficiary form, which includes the special consent documentation.
BENEFICIARY INFORMATION
ADDITIONAL OPTIONS
q I would like to view my account on Internet Banking.
Note: Enrollment in Internet Banking allows access to all services including online Bill Payment. You will receive a link at the email address listed under primary information, which will allow you to set up your login, password and security questions. Your security code required after clicking the link is the last 4 digits of your Social Security Number for consumer accounts or the last 4 digits of the EIN for business accounts.
q I would like to order standard wallet checks for my Health Savings Account.
q I would like to order a free Visa debit card for my Health Savings Account (HSA), issued in my name, to use for normal distributions only.
q I would like to order a second free Visa debit card for my HSA, issued for the authorized signer listed below, to use for normal distributions only.
Name:
Note: Purchases made with this debit card will be reported by the Bank as normal distributions. I understand I should not use my debit card or checks for non-qualifying or non-medical purposes and that I am responsible for any IRS penalties.
AUTHORIZED ACCOUNT SIGNER OPTIONS
If you desire an authorized signer on the Health Savings account, please list their information below:
Name: Last 4 of SSN:
Cell Number:
Email Address:
(Attach copy of Driver’s License or State Issued ID) HSA Account Holder Signature