Health Savings Account Payroll Deduction Authorization Form
Employee Name SSN
E-mail
Phone
Client Company
Annual Deductible ___ Single ___ Family Coverage Contribution Details Indicate election amount to be deducted from your pay check and when you want it deducted. (ex. $1200 spread out on all paychecks OR $1200 in the next three payrolls)
I authorize Employer Solutions Group to initiate payroll deductions, and adjusting entries thereto, from my pay check, and to deposit the value of such payroll deductions to the health savings bank account I maintain in connection with the HSA program. I understand that I may revoke this authorization by giving at least ten (10) days written notice of cancellation to Employer Solutions Group at the address listed on this form, and that the revocation will not apply to transaction initiated prior to ESG’s receipt of the notice, or to adjusting entries on previous transactions. I represent that I am the owner of the account named below and that I have the legal right to provide this authorization.
________________________________________________ Signature of Employee Date
For Benefit Use Only
Date Request Received
Date Entered into HRP
Employer Solutions Group 4844 North 300 West, Suite 100 Provo, UT 84604
Tel: 801-223-7007 1-888-810-8187 Fax: 801-431-7890