Please fill out the fields in the form below. One of our representatives will contact you within one business day to complete the process.

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Health Savings Account (HSA)

    To determine if you are eligible for a Health Savings Account please complete and submit the form below.

  • Are you a new customer?

    OKAre you a new customer? is required

Your Contact Information

  • OKName is required
  • Phone

    --
    OptionalOKPhone is required
  • OKE-mail is required
  • How do you wish to be contacted?

    OKHow do you wish to be contacted? is required

Answer the Following Four Questions:

    HSA ELIGIBILITY CERTIFICATION

    I am eligible to establish an HSA and certify the following. (All must be answered “true” to be eligible to establish an HSA to receive regular or catch-up contributions).

  • I am covered under a qualifying High Deductible Health Plan (HDHP)

    OKThis field is required.
  • I am not covered under any other insurance plans that are not HDHP (with certain exceptions for plans providing certain limited types of coverage).

    OKThis field is required.
  • I am not enrolled in Medicare

    OKThis field is required.
  • I am not able to be claimed as a dependent on someone else's tax return

    OKThis field is required.
  • OK is required