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Online Forms

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To view employer forms, click here.


 

Maintenance


Sign up for an HSA online
Click on the above link to sign up for an HSA today, or enroll by mail.

Account Information Change Form
Change your name, designation of beneficiary or authorized signer.

Authorized Signer
Log in to Internet Banking to add an Authorized Signer to your account, or complete this form.

Authorized Signer Revoked
Remove an authorized signer from an account.

Designation of Beneficiaries
Designate, change or remove a beneficiary.

Change Address
Log in to your Internet Banking account and click “Profile” to change your address.


 

 

 

 

 

Account Access

Contributions
Contribution Form
Make a contribution online, or submit this form.

Transfers & Rollovers 
MSA to HSA Rollover Form 
HSA Transfer/Rollover Form
IRA to HSA Transfer Form

Withdrawals
Order Checks and Debit Cards 
Complete the form through Internet Banking.

Excess Removal Form
Remove funds that exceed the contribution limit.

Distribution Reversal Form
Return funds used for non-eligible expenses.

Withdrawal Form
Withdraw HSA funds.

 

Disclosures


E-Sign Agreement
Download information on electronic recordkeeping of disclosures, documents and statements. 

Account Disclosures
Download disclosures associated with your HSA.

Interest Rates and Service Fees

Online Banking Agreement
Download the agreement terms associated with using Internet Banking.

Privacy and Opt Out Notice
Download statements regarding your right to privacy.

Tax Resources

IRS Form 1099-SA
Reports your HSA distributions.

IRS Form 5498-SA
Reports your HSA contributions.

Instructions for IRS Forms 1099-SA and 5498-SA

IRS Form 8853
File your MSA contributions and distributions.

Instructions for IRS Form 8853

IRS Form 8889
File HSA contributions, distributions and tax deductions.

Instructions for IRS Form 8889