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 by MarvinGolden

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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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