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?

  • Yes
  • No
  OK Are you a new customer? is required

Your Contact Information

• Name
  OK Name is required
• Phone
  Optional OK Phone is required
• E-mail
  OK E-mail is required

• How do you wish to be contacted?

  • Phone
  • Email
  OK How 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)

  • True
  • False
  OK This 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).

  • True
  • False
  OK This field is required.

• I am not enrolled in Medicare

  • True
  • False
  OK This field is required.

• I am not able to be claimed as a dependent on someone else's tax return

  • True
  • False
  OK This field is required.
• OK is required