What Is a Health Savings Account?

Paycheck

HSA

Pay Bills Tax-Free

Why Should I Choose an HSA?

An HSA Puts More Money Into Your Pocket.

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An HSA Gives You More Control Over How You Spend Your Health Care Dollars.

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What Is a Health Savings Account?

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If I’m Healthy, Is an HSA Right for Me?

Who Is Eligible to Have an HSA?To be eligible to open an HSA, you must meet the following requirements:

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Here Are the Ways an HSA is Like a 401(k):

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Withdraw HSA

funds with no penalty

How Can I Build the Balance in My HSA?

Your HSA Up to the Yearly IRS Limits.

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You Can Roll Over Funds From Other Tax-Advantaged Accounts.

Whose Medical Expenses Can I Pay for Out of My HSA?

Spouse and Dependents

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Health Savings AccountEmployee Enrollment Form

This enrollment form is to open a Health Savings Account that is used to accumulate assets for the payment of qualified healthcare expenses.Your Health Savings Account is your financial asset even if you change employers or health plans. Toopena Health Savings Account youmust meet threecriteria: 1) Youmust be covered by a qualified high deductible health plan, 2) You cannot be covered by another healthplan,including Medicareand3) You cannot be claimed as a dependent on another individual�s tax return.

Name: First: ___________________________ Last: ______________________________________ Middle Initial: ________

Street Address: Street: _________________________________________________________________________________________

City: _____________________________________________ State:________________ Zip: __________________

Mailing Address: Street: _________________________________________________________________________________________

City: _____________________________________________ State:________________ Zip: __________________

Date of Birth: _______________ Email: ____________________________________________________________

Contact Phone: (______) ______________________ Social Security Number: ______________________________ Gender: . M . F

Insurance Coverage: Coverage Effective Date __________________________ Coverage Type: . Single . Family

A $10.00 enrollment processing fee will be charged to your employer for submitting a paper enrollment application. There is no enrollmentprocessing fee if your employer enrolls you online via their HealthEquity Employer Portal.I accept the terms of the HealthEquity HSA enrollment form and the HSACustodial Agreement. The HSA Custodial Agreement isavailable by clicking on �Forms and Documents� in the Resource Center on www.healthequity.com.In compliance with the USA PATRIOT Act, HealthEquity must verify the identity of all customers seeking to open an HSA. As part of thisidentity verification process, you may be asked to provide additional information and/or documentation before your account can beestablished.

_____________________________________ ________________________________________________ ______________Print Name Signature Date

The balance in your HSA is insured by the Federal Deposit Insurance Corporation (FDIC), subject to applicable deposit limits.

Personal Information

Authorization and Certification

Employer Name

Qualified for a Health Savings Account

I Choose the following contribution level, Premium Deductions

Per Pay Check (Pre Tax):

Coverage Type:___ Single $3 50 limit 20 8 ____ Family $6,900 limit 2018

$______________________ / ________52_________ = $___________________

Annual Election Amount Number of Paychecks Amount per Paycheck