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Employer Forms
Employer Information [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.
Employer Contribution [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.
HSA Application [PDF] [On-line Application]
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/HRA from another administrator. If you have already closed your HSA with the other administrator and received a check please check "rollover".
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.
Additional Contributions [PDF]
To make additional contributions to your HSA please complete, sign and submit this form along with your contribution. Note: check your total contribution limit with our Contribution Worksheet [PDF].
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.
