A: Your Bank Street Address
Your Bank City, State ZIP
Employer Forms
You must complete, sign and deliver to us. Your transaction cannot be processed until it is properly received. Please verify receipt if you do not receive notification from us in a reasonable time period.
Employer Forms
Employer Information Worksheet [PDF] [Excel]
This form provides us with basic information on the employer (name, contact person, type of plan) and is designed to be the first form completed by the employer.
Employee Contribution Worksheet [PDF]
For employers contributing to employee HSAs. Use this form (our your own) to provide us with a breakdown of the contribution between individual employees. Use this form to add and remove employees also.
Transfers and Rollovers [PDF]
Use this form to transfer an HSA/MSA/FSA/HRA from another administrator. If you have already closed your HSA with the other administrator and received a check please check "rollover".
Model Notice of HSA Contributions [PDF]
Employers must provide this form to employees that fail to open an HSA when the employer is making HSA contributions.
Employee Forms
Change of Beneficiary [PDF]
Complete this form to identify who you would like to inherit your HSA or to change your beneficiaries. Note: if you designate your spouse, your HSA will transfer tax free and become your spouse's HSA.
Other Distributions [PDF]
If you would like to take a distribution to pay for a medical expense and do not want to use your checking account or debit card, you may also submit a completed Distribution form.
