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Health Savings Account Application

Client Information (Step 1 of 4)

Background
Contact Information
Physical Address
Mailing Address

Identification Information (Step 2 of 4)

Background

You will be asked to provide a clear copy of valid identification for verification. Acceptable forms of identification include: two forms of identification from the list below - one of which must be from the primary identification list.

Primary Identification
  • Driver License
  • Passport
  • State-Issued Identification Card
  • Military Identification
Additional Identification
  • An Additional Primary Identification
  • Student Identification Card
  • Company Identification Card
  • Credit Card
Primary Identification
Secondary Identification
Please Choose A Password To Be Used When You Call Us
Eligibility Questions
If you answered YES to question 1 and NO to questions 2 through 4, you are eligible to establish an HSA.

Beneficiary Information (Step 3 of 4)

Beneficiary 1

All Primary Beneficiaries should total 100% and all Contingent Beneficiaries should total 100%

Beneficiary 2

Make sure all your answers are correct then submit this form.