MidCountry

 

 

Learn more about Health Savings Accounts

Online HSA Application

Please complete all fields below. After clicking submit you will have a chance to review and edit your information. Once all of your information is correct, you may print out the application and bring it with a legible copy of your driver's license or valid ID to any Bank branch. Or call our Customer Service Department toll-free at 1-877-813-3030.

Part 1. HSA Account Holder Personal Information

Title
 First Name
MI
 Last
Address
City
 State
 ZIP
CHECK HERE IF YOU HAVE A DIFFERENT MAILING ADDRESS
Mailing Address (if different)
City
 State
 ZIP
Drivers License/State ID#
 State
 Expiration Date
Work Phone
 Home Phone
 E-mail
Date of Birth
 Place Of Birth
Mother's Maiden Name
SSN#
 Marital Status
 Type of Insurance
Internet Banking ID (optional) 6-10 Characters, Case sensitive
You will receive your debit card, HSA Checks and on-line banking instructions via the US mail.

Part 2. Contribution Information

My Initial Contribution will be Provided
By me Personally:     

Part 3. Designation of Beneficiary (Optional)


PRIMARY BENEFICIARIES   (CLICK HERE TO ADD MORE PRIMARY BENEFICIARIES)
Name
Address
Percentage
SSN#
Relationship
Date of Birth
Name
Address
Percentage
SSN#
Relationship
Date of Birth

Check here if you named someone other than your spouse as a Primary Beneficiary.


CONTINGENT BENEFICIARIES  (CLICK HERE TO ADD CONTINGENT BENEFICIARIES)

Part 4. Additional HSA Account Signer (Optional)

If you want your spouse or other party to have access to your HSA please complete this section. There is no charge for adding a second signer to your account.

Title
 First Name
MI
 Last
Mailing Address (if Different from HSA Owner)
City
 State
 ZIP
SSN#
 Date of Birth
 Place of Birth
Mother's Maiden Name (Additional Signer)
  
Drivers License/State ID#
 State
 Expiration Date
Check here if you would like a debit card for the authorized signer (Optional)
            

 

 

 

Questions? Contact a customer service representative at 877.813.3030