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Health Bank Card® Health Savings Account Enrollment Agreement This is not your Medical Insurance Policy; contact your insurance carrier (or agent) to make changes to your insurance Please contact Health Bank Card at 605-977-0117, 2301 W Russell Street, Sioux Falls, SD 57104 if you have any questions. Original Election Change Election I am currently enrolled in the health plan I am in the waiting period for my health plan Account Holder Information Employee First Name Middle Initial Employee Last Name Nickname Social Security Number Date of Birth Email Address Mother’s Maiden Name (MM/DD/YYYY) Home Phone # Work Phone # Fax # Cell Phone # Home Address (If you have a PO Box, please City State Zip include both the PO Box and the street address) Driver’s License # State of Issuance Expiration Date Copy of Driver’s License must be Have you lived in this State If not, where? for the past 5 years? included with this application Yes No Employer Information Employer Name Employer Mailing Address City State Zip SD Insurance Carrier or Plan Group Health Plan ID # Member Group Health Plan ID# Adminstrator Effective Date of Insurance Policy Insurance Deductible Plan Year Deductible Year Employer Phone # Employer Fax # HSA Custodian Custodian Address Custodian City, State, Zip First National Bank 955 Main Street, PO Box Sturgis SD 57785 279 Member Election I am enrolled in single coverage through my group health plan, and I have no dependents. I am enrolled in single coverage through my group health plan, and I do have dependents. I am enrolled in family coverage through my group health plan. Each member will automatically receive one Health Bank Card® debit card. Please check here if you wish to receive an additional Health Bank Card™ debit card for an authorized signer. In addition, I elect to receive a checkbook for my HSA (additional bank charges apply) Please Check One (1) 25 duplicate checks and 10 deposit slips ($6.65) 50 duplicate checks and 20 deposit slips ($8.20) Blue Yellow Green Authorized Signers (Optional) Regulations require that only one individual hold an HSA. An account holder may want a spouse, or another third party, to have access to funds within the HSA by naming them as an authorized signer. I (account holder) designate the following individual signer(s) on my Health Savings Account. I understand these individuals will receive a Health Bank Card™ debit card for use on this account (additional fee applies). First Signer-employee does not need to sign here. First Name Middle Initial Last Name Social Security Number Date of Birth Email Address Phone # (MM/DD/YYYY) Country of Citizenship Occupation Driver’s License # State of Issuance Home Address City State Zip Signature of Authorized Signer Second Signer First Name Middle Initial Last Name Social Security Number Date of Birth Email Address Phone # (MM/DD/YYYY) Country of Citizenship Occupation Driver’s License # State of Issuance Home Address City State Zip Signature of Authorized Signer You MUST include a copy of the authorized signer’s driver’s license. Contribution Information Annual Health Plan Contribution for Tax Deductible How much is the single deductible? $_________ Year: How much is the family deductible? $________ Maximum Employer and Employee HSA contribution Single: $3,000 Family: $5,950 For 2009 Participants in an HSA cannot be covered by another health plan except “permitted” insurance products. Contribution amounts may be increased during the year by making a written request to Health Bank Card® Unless there is a qualifying event, contribution amounts may not be decreased during the year. Contribution Election Per Pay X Pay Periods/Year = Annual Employee Contribution Period Employee HSA Contribution $ X = $ Employee Catch Up Contribution $ X = $ Only applicable for employees age 55 to age 65 ($1,000 for 2009) Total Employee Annual Contribution $ READ BEFORE SIGNING: I hereby elect $_____________ per Pay Period to be deducted, by my employer, from my paychecks for deposit into my HSA. I understand that any amounts advanced to me to cover a cost exceeding the balance in my account will be considered a loan payable to HBCI® and be handled as an advance of my payroll, and as such, will be withheld from any terminal benefits payable at the time of my separation from the company. HBCI® will employ debt collection measures if the amount of terminal benefits withheld does not repay the loan amount in full. A member may obtain an advance to cover DEDUCTIBLE expenses that exceed the current account balance. This advance is interest FREE, I agree that the monthly fee to maintain my Heath Bank Card® Health Savings Account may be deducted from my account in the event that the employer is NOT going to pay the fee for me. I certify this information is true and accurate. I also certify that I am eligible to participate in the HSA and am not covered by other insurance that would disqualify me from participation. I authorize the bank to provide HBCI® all data necessary to maintain this account and provide the value added services offered. I/We authorize the transfer of information, as necessary, from my/our account at HBCI® for the purpose of providing bank account summary information. The account holder is responsible for the establishment and maintenance of this account pursuant to Federal guidelines. HBCI® is here to assist the account holder in accomplishing this. I authorize the insurance carrier or plan administrator named above to disclose claims information concerning myself or any of my dependents to HBCI® to maintain this account and provide the value added services offered. HBCI® will not activate the HSA unless all authorization boxes are checked. Primary HSA Beneficiary Designation Name Relationship Social Security Number Mailing Address City, State and Zip Secondary HSA Beneficiary Designation Name Relationship Social Security Number Mailing Address City, State and Zip Spousal Consent: This section should be reviewed if either the trust or the residence of the HSA Account Owner is located in a community or marital property state and the HSA Account Owner is married. Due to the important tax consequences of giving up one’s community property interest, individuals signing this section should consult with a competent tax or legal advisor. Current Marital Status I Am Not Married – I understand that if I become married in the future, I must complete a new HSA Designation of Beneficiary form. I Am Married – I understand that if I choose to designate a primary beneficiary other than my spouse, my spouse must sign below. I am the spouse of the above-named HSA Account Owner. I acknowledge that I have received a fair and reasonable disclosure of my spouse’s property and financial obligations. Due to the important tax consequences of giving up my interest in this HSA, I have been advised to see a tax professional. I hereby give the HSA Account Owner any interest I have in the funds or property deposited in this HSA and consent to the beneficiary designation(s) indicated above. I assume full responsibility for any adverse consequences that may result. No tax or legal advice was given to me by the Custodian. ______________________________________________ _________________________ Signature of Spouse Date _________________________________________ ______________________ Signature of Witness Date This Beneficiary Designation Form supercedes any Beneficiary Designation Form previously filed for this Health Savings Account. The designation of beneficiary listed above is subject to all terms and provisions of the Health Savings Account Disclosure and Custodial Agreement and shall be effective only if received by First National Bank (Sturgis HSA division) prior to the death of the account holder. This designation applies to all of the account holder’s HSA assets and interest held in trust that remain undistributed at the account holder’s death. If the above designated beneficiary is not living at the time of the account holder’s death, payment of funds shall be made to any living contingent beneficiaries. This designation may only be altered by filing a written change with the First National Bank (Sturgis HSA division). I hereby understand that First National Bank (Sturgis HSA division) will establish a Health Savings Account (HSA) in my name. I acknowledge that this account will be established according to the Account Disclosure and Health Savings Custodial Account Agreement and that I have received them with this document. I certify that First National Bank (Sturgis HSA division) is authorized to act in accordance with any future documents bearing my signature. I understand that I may revoke this agreement at any time by written notice to First National Bank (Sturgis HSA division) and account assets will be returned to me according to the HSA Federal Regulations. All of the information provided by me is true and correct and may be relied on by the Trustee or Custodian. I certify that I am eligible for the type of contribution being made. I will assume total responsibility for (1) making sure that all HSA contributions I make are within the limits set by the tax laws, and (2) the tax consequences of any contributions (including any rollover contributions) and any distributions. I understand the terms and conditions which apply to my HSA are contained in my HSA plan agreement and I agree to be bound by those terms and conditions. I also understand that Federal law requires all financial institutions to obtain and verify personal information that will identify those individuals who open a new account. I hereby acknowledge that the information contained in this document will be used to verify that I am not associated with the funding of terrorist groups or other money laundering activities. First National Bank (Sturgis HSA division) will accept enrollment in the group health plan as verification of compliance with the Federal law. Account Holder Signature: _______________________________________________________________ Date: _____/_____/_________ Print Name: ___________________________________________________________________________ W-9 Under penalties of perjury, I certify that (1) the Social Security Number set forth in this agreement is my correct Taxpayer Identification Number (interest paid, if any, will be reported under this number), and that (2) I am exempt from backup withholding, or I am no longer subject to backup withholding, and (3) that I am a U.S. person (including a U.S. resident alien). Cross out item (2) above if you have been notified that you are subject to backup withholding because of underreporting of interest or dividends on your tax return. Account Holder Signature: _______________________________________________________________ Date: _____/_____/_________ Print Name: ___________________________________________________________________________ YOU NEED TO SIGN TWICE ON THIS PAGE If you incur an expense that exceeds the balance in your HSA, you have the option to request an advance of the needed funds. You can do this by calling Health Bank Card, Inc. at 605-977-0117. We will advance the funds into your account to help cover the amount of your deductible expense in excess of your current account balance. The maximum amount of the available advance is equal to the amount of your annual contribution or your annual deductible, whichever is less. If you wish to increase your contribution level to the annual deductible amount, you may do so at the discretion of your Human Resources / payroll department. There is a monthly fee to maintain your Health Savings Account. This fee will be paid from the HSA unless the employer has agreed to pay the fee on your behalf. The monthly fee is $2.00. If you discover that you will need an advance of funds after business hours, you can pay the expense out of your pocket and reimburse yourself from the HSA after the advance has been processed. Please do NOT write a check that could possibly overdraw your account as you will be subject to the overdraft charges. The advances into your HSA are tax-free and will be repaid out of your already scheduled payroll deductions (or your modified payroll deductions). Please contact Amy Kleinberg at 605-977-0117 with any questions.
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