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Account Opening
HSA Application [PDF]
Use this application to open your HSA. Note: if you are participating in an employer plan, you can skip Section 2 as that information will be provided by your employer.
Transfers and Rollovers [PDF]
Use this form to transfer an HSA/MSA/FSA/IRA from another administrator. If you have already closed your HSA with the other administrator and received a check, please use the HSA Contributions Form.
Custodial Agreement [PDF]
This is the legal agreement between you and your HSA custodian for your Health Savings Account. The 5305-C is provided by the Internal Revenue Service.
On-going Account Maintenance
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.
HSA Contribution Form [PDF]
To make additional contributions to your HSA please complete, sign and submit this form along with your contribution. Note: you may check your total contribution limit with our HSA Contribution Worksheet [PDF].
HSA Distribution Form [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 sumit a completed Distribution form.
Excess Contribution [PDF]
If you contribute too much to your HSA, you need to remove the “excess” amount plus any interest earned on the excess by your tax filing due date to avoid penalties. Use this form to remove excess contributions.
Re-Contribution of Mistaken Distribution [PDF]
Use this form if you mistakenly take a distribution for an expense that you thought was “eligible”. Re-contributions must be corrected by your tax filing due date following the year you should have known of the mistake.
Death Distribution [PDF]
In the case of a death, the account holder's HSA will pass to the designated beneficiaries upon submission of a copy of the death certificate and Distribution Form. Note: surviving spouses inherit the HSA as their HSA, tax-free.
