Election Form For The Health Savings Account Form

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P.O. Box 43653 Louisville, KY 40253-0653 (502) 244-1161 (800) 919-BMSI
FAX (502) 244-1162
ELECTION FORM FOR THE HEALTH SAVINGS ACCOUNT- HSA BANK
Employer_______________________________________ Employee Name_______________________________________
Social Security # _________________________________ Date of Birth __________________________________________
Mailing Address ______________________________________City ____________________State_________ Zip_________
(Please note: We cannot set up an HSA with a PO Box. Please provide a Physical mailing address. Cannot be a PO Box)
Home Phone (_____) _______________________________ E-mail ____________________________________________
Form of ID ________________________________________ ID Number_________________________________________
(Drivers License, State ID, or Passport)
Spouse’s or Qualified Dependent’s Full Name (for an extra HSA Debit Card) _______________________________________
(Must be qualified dependent under IRS rules and regulations. If you wish to order extra cards, contact BMS after the start of the Plan Year.)
Citizenship Status __________________________________ Country of Citizenship ________________________________
Job Title _____________________________________________________________________________________________
**** ALL FIELDS ARE REQUIRED AND MUST BE COMPLETED IN ORDER TO SET UP YOUR HEALTH
SAVINGS ACCOUNT WITH HSA BANK. ELECTION FORMS NOT COMPLETED IN THEIR ENTIRITY WILL
CAUSE A DELAY IN THE ACCOUNT SET UP AND RECEIPT OF YOUR HSA BANK DEBIT CARD.***
1
OPTION
HEALTH SAVING ACCOUNT AGREEMENT
YES
I
elect to contribute $___________ (before taxes) for the PLAN YEAR, which is $__________ per pay period (please calculate
based on the number of pays in your Plan Year) to fund my account that pays for qualified healthcare expenses covered by my High
Deductible Health Plan (HDHP) as described in IRS Code Section 223. 1.) I understand that I can only participate in this Plan if I
am currently enrolled in my Employer’s HDHP/HSA Health Plan. 2.) I understand that I am not entitled to Medicare Benefits. 3.) I
understand that the HDHP Plan must meet minimum requirements and deposits cannot exceed the indexed maximums outlined by
the IRS.
I agree to follow all rules and regulations as outlined by the IRS with respect to HSA Account and I understand I must
complete any applicable Custodial Bank Applications in order to establish my HSA Account with an IRS approved Custodian.
OPTIONAL : My Employer has elected to contribute $____________for the PLAN YEAR which is $________ per pay period.
(Must be completed by the Employer to be processed by BMS.)
NO
I decline this option for this Plan Year and understand that I will lose all tax savings that I could receive as a participant.
2
OPTION
AGREEMENTS TO SAVE TAXES ON INSURANCE PREMIUMS
YES
On the appropriate benefit enrollment form, I have enrolled in certain employer-sponsored insurance benefits (i. e. health insurance.)
I understand that my share of the premium for these employee benefits will automatically be paid with pre-tax dollars. I also
understand that if my required contributions for these insurance benefits are increased or decreased while this agreement is in
effect, my taxable income will automatically be adjusted to reflect that change.
NO
I decline this option for this plan year and understand that I will lose all tax savings that I could receive as participant.
My employer and I agree that my taxable income will be reduced during the year by an equal portion of the benefit elections (1-2) set forth above
and that qualified expenses will be paid on a tax-free basis, I understand that I may change my election only in the event of certain changes in my
status and that, prior to the first day of each Plan Year, I will be offered the opportunity to change my benefit election for the upcoming Plan Year. I
have also read and understand the Important Information provided with enrollment materials.
Employee Signature: ______________________________________________________________Date_______________________________
Plan year start (mm/dd/yy) _____/______/_____ and end _____/_____/_____
TO BE COMPLETED BY EMPLOYER
First payroll start date _____/____/_____ Pay Cycle ___________________
Custodial HSA Application Submitted with this Election Form____________(new accts. only)
11/10 version

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