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                                                                               Principal Life            HSA Sponsor/Employer
                                                                               Insurance Company         Enrollment Form

Sponsor/Employer Information                                                                    HSA number
Company name                                                                                                       Tax ID number

Street address

City                                              State                                         ZIP

Decision Maker/Contact Name                               Phone                  E-mail
                                                          (     )      -

HSA Administration

Primary Administrator Information - Please provide information for Human Resources or Payroll personnel that will be
using the Direct Connect system to make contributions and pay fees. Principal Life Insurance Company will contact this
individual and setup Direct Connect access. Some personal information (ex. social security number) will be required to
grant secure access.
Primary Administrator Name                           Email                                                 Phone
                                                                                                           (   )      -
Unit Information - All employees will be placed in a single unit. If additional units are needed (ex. by location/division), this
may be done at the Sponsor/Employer’s convenience utilizing administrator capabilities within the Direct Connect system.

Fee Information (must choose one)
                       SM                                                                  SM
       Principal HSA                                                Principal HSA Select
Setup fee: $25.00                                             Setup fee :$0.00
Monthly maintenance fee: $2.39 (includes tax)                 Monthly maintenance fee: $3.18 (includes tax)

Setup fee paid by:           Sponsor       Participant        Monthly Maintenance fee paid by**:         Sponsor          Participant
** Monthly Maintenance Fee paid by Sponsor/Employer requires completion of form GP 54788.

Special Instructions




Sponsor/Employer Agreement of Understanding

I confirm that the information is accurate to the best of my knowledge.
At its sole discretion, Principal Life may permit the Sponsor to change its fee schedule election. A processing fee may
apply. Principal Life may also make additional fee schedules available at its discretion.
Signature:                                                                                      Date:
Company Name:                                                                                   Title:




GP 54358-4                                                    Page 1 of 2                                                     10/2009
                                                                                Principal Life          HSA Sponsor/Employer
                                                                                Insurance Company       Enrollment Form


                      Principal Life Group                                          Principal Retirement & Investor
                      Product Information                                            Services Product Information
Plan number(s):                                                      Plan number(s):
(Ex: Medical, Dental, Disability, Life   P12345)                     (Ex: 401K and Pension 123456 or Share Plan 1234567)

Account Manager:                                                     Account Executive:

HSA Sale Information
Sales channel
             Insured Health (insured medical)                         Retirement & Investor Services (401(k), pension, ESOP)
             Specialty Benefits (non medical)                         Rogers Benefit Group
             National Accounts (self-funded medical)                  Excelsior
             Career agents                                            Standalone (no other PFG products)
Broker Name (if applicable)                            Social security number      Email                       Phone
                                                                                                               (   )    -
Principal Sales Representative Name                    PFG User ID                 Email                       Phone
                                                                                                               (   )    -

If form has missing information, contact:
       Sponsor/Employer (Primary Administrator)                                      Sales Representative
       National Accounts Account Manager/HSA Relationship Manager                    Broker

Other notes:
       Not using Direct Connect (processing fee will be charged per transaction)




The Sponsor/Employer must sign this form. The entire form, along with GP 54788, (if applicable), should be
submitted to one of the following:
FAX to:                                                                                    Mail to:
866-865-8900                                            OR                                 Principal Life Insurance Company
Attn: HSA Processing                                                                       Attn: HSA Processing
                                                                                                        th
                                                                                           1275 NW 128 Street
Email to:                                                                                  Clive, IA 50325
hsaprocessingteam@exchange.principal.com




GP 54358-4                                                Page 2 of 2                                                       10/2009

								
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