Health Savings Account Application

Transcription

1 Health Savings Aount Appliation

2 FOR BANK USE ONLY: ACCOUNT # CUSTOMER # Health Savings Aount (HSA) Appliation ALL FIELDS MUST BE COMPLETED. Missing fields may delay the aount opening proess and possibly result in a returned appliation. HSA Aount Type (hek one) Traditional HSA OR HSA with Investments (balane must exeed $3,000) Health Insurane Plan Coverage: Tax Year: Aount Holder Information: If you are enrolling through your employer, please list your employer here: First Name: Middle Initial: Last Name: Home Address: City: State: ZIP: Soial Seurity Number/TIN: Date of Birth (mm/dd/yyyy): Address: Home Phone: Cell Phone: Drivers Liense #: Issue Date: Exp. Date: Drivers Liense State: Oupation: OPTIONAL: Agent/Authorized Signer Information: (If retired, list previous oupation) Due to IRS Regulations, HSAs are only allowed to have one aount owner. However, you are allowed to have an Agent/Authorized Signer added to your aount. Agents are able to gain aount information suh as balane and transation history and make purhases with heks and a debit ard. Agents will NOT be allowed to make investment deisions or lose the Health Savings Aount. First Name: Middle: Last Name: Home Address: City: State: ZIP: Soial Seurity Number: Date of Birth (mm/dd/yyyy): Address: Home Phone: Cell Phone: Drivers Liense #: Issue Date: Exp. Date: Drivers Liense State: Oupation: (If retired, list previous oupation)

3 Benefiiary Information: At the time of my death, the primary benefiiaries named below will reeive my HSA assets. If all of my primary benefiiaries die before me, the ontingent benefiiaries named below will reeive my HSA assets. In the event that a benefiiary dies before me, suh benefiiary s share will be realloated on a pro-rata basis to the other benefiiaries that share the deeased benefiiary s lassifiation as a primary or ontingent benefiiary. If all of the benefiiaries die before me, my HSA assets will be paid to my estate. If no perentages are assigned to benefiiaries, the benefiiaries will share equally. If the perentage total for eah benefiiary lassifiation does not equal 100 perent, any remaining perentage will be divided equally among the benefiiaries within suh lass. This designation revokes and supersedes all earlier benefiiary designations whih may apply to this HSA. Aount Holder Information: Name of Benefiiary SSN/TIN DOB Primary Contingent Perent

4 All fields must be ompleted. Missing fields may delay the aount opening proess and possibly result in a returned appliation. Bakup Withholding Certifiations TIN/Soial Seurity Number a TAXPAYER ID NUMBER The Taxpayer Identifiation Number shown above (TIN) is my orret taxpayer identifiation number. a BACKUP WITHHOLDING I am not subjet to bakup withholding beause I have not been notified that I am subjet to bakup withholding as a result of a failure to report all interest or dividends, or the Internal Revenue Servie has notified me that I am no longer subjet to bakup withholding. EXEMPT RECIPIENTS I am an exempt reipient under the Internal Revenue Servie Regulations. I ertify under penalties of perjury the statements heked in this setion and that I am a U.S. person (inluding a U.S. resident alien). Signature Date Signatures If this HSA is being established with a regular ontribution, I ertify that I am overed by a qualified high dedutible health plan (HDHP), and that I am not overed by a health plan other than an HDHP that provides any of the same benefits as an HDHP. If this HSA is being established with a rollover or transfer ontribution, I ertify that the rollover or transfer assets are from another HSA or Arher Medial Savings Aount (MSA), Flexible Spending Arrangement (FSA) or Individual Retirement Aount (IRA). I ertify that the information provided by me on this Appliation is aurate, and that I have reeived a opy of the Appliation, Health Savings Aount Dislosure Statement, and amendments thereto. I assume sole responsibility for all onsequenes relating to my ations onerning this HSA. I understand that I may revoke this HSA on or before seven (7) days after the date of establishment. I have not reeived any tax or legal advie from the ustodian, and I will seek the advie of my own tax or legal professional to ensure my ompliane with related laws. I release and agree to hold the HSA ustodian harmless against any and all laims or losses arising from my ations. I also ertify that everything I have stated in this HSA Aount Appliation/Signature Card and on any attahment is orret. By signing below I authorize you to hek my redit aount. I authorize you to take steps to verify my identity. I understand that I may be asked several questions and to provide one or more forms of identifiation to fulfill this requirement. Further, I understand that in some instanes, outside soures may be used to onfirm the information I provide and that any information I provide is proteted under Choie Finanial s Privay Poliy and federal law. Signature of HSA Owner Date Signature of Agent/Authorized Signer (If eleted, signature is required) Date 5

5 Choose any or all of the onvenient aount options. If no aount options are seleted, you will not reeive any of the following options other than a monthly paper statement. Cheks (available for a fee) Debit Card (omplimentary) 1 1 Debit Card OR 2 Debit Cards Statement Delivery Options (Please selet one): estatement (with free hek images) address is required: Paper Statement with images ($2 a month) 1 Certain restritions may apply. Subjet to approval. You may be harged foreign ATM fees. Wath Your Mail! One Choie Finanial reeives your ompleted appliation, your HSA will be opened. Please wath your mail for the following: Aount Welome Kit. Your aount welome kit will provide you with your aount number, important aount information, dislosure information and our ommitment to your privay. Cheks (if ordered). Cheks will arrive business days from approval of HSA appliation. Debit Card(s) (if ordered). Your Debit Card(s) and will arrive in approximately two weeks from approval of HSA appliation. If you have any questions or omments, please all our HSA Helpline at or [email protected]. FAX Attn: HSA Department SUBMIT COMPLETED FORM TO ONE OF THE FOLLOWING: MAIL Choie Finanial - HSA Dept rd Ave. S. Fargo, ND [email protected] We reommend sending in a seure format. Congratulations and thank you for hoosing Choie Finanial as your HSA provider! We look forward to working with you well into the future. 6

6 Revised 08/15 FACTS Why? What? WHAT DOES CHOICE FINANCIAL GROUP DO WITH YOUR PERSONAL INFORMATION? Finanial ompanies hoose how they share your personal information. Federal law gives onsumers the right to limit some but not all sharing. Federal law also requires us to tell you how we ollet, share, and protet your personal information. Please read this notie arefully to understand what we do. The types of personal information we ollet and share depend on the produt or servie you have with us. This information an inlude: Soial Seurity number and inome Aount balane and payment history Credit history and redit sores When you are no longer our ustomer, we ontinue to share your information as desribed in this notie. How? All finanial ompanies need to share ustomers personal information to run their every day business. In the setion below, we list the reasons finanial ompanies an share their ustomers personal information; the reasons Choie Finanial Group hooses to share; and whether you an limit this sharing. Reasons we an share your personal information: Does Choie Finanial Group share? Can you limit this sharing? For our everyday business purposes - suh as to proess your transations, maintain your aount(s), respond to ourt orders and legal investigations, or report to redit bureaus For our marketing purposes - to offer our produts and servies to you For joint marketing with other finanial ompanies Yes Yes We don t share For our affiliates everyday business purposes - information about your transations and experienes For our affiliates everyday business purposes - information about your reditworthiness For non-affiliates to market to you Yes We don t share We don t share Questions? Call or or [email protected] 7

7 Page 2 Who we are Who is providing this notie? Choie Finanial Group What we do How does Choie Finanial Group protet my personal information? How does Choie Finanial Group ollet my personal information? To protet your personal information from unauthorized aess and use, we use seurity measures that omply with federal law. These measures inlude omputer safeguards and seured files and buildings. We ollet your personal information, for example, when you: Open an aount or deposit money Pay your bills or apply for a loan Use your debit or redit ard We also ollet your information from redit bureaus, affiliates or other ompanies. Why an t I limit all sharing? Federal law gives you the right to limit only Sharing for affiliates everyday business purposes - information about your reditworthiness Affiliates from using your information to market to you Sharing for non-affiliates to market to you. State laws and individual ompanies may give you additional rights to limit sharing. Definitions Affiliates n-affiliates Companies related by ommon ownership or ontrol. They an be finanial and non-finanial ompanies. Choie Finanial Insurane Choie Finanial Leasing Companies not related by ommon ownership or ontrol. They an be finanial and non-finanial ompanies. Choie Finanial Group does not share with nonaffiliates so they an market to you. Joint Marketing A formal agreement between non-affiliated finanial ompanies that together market finanial produts or servies to you. Choie Finanial Group does not jointly market. 8