Health Savings Account (HSA) Employee Contribution Form
I. Employee Enrollment
Employer Name: CITY OF MERIDEN
Your Name (last, first, middle)
Social Security Number
Date of Birth
Mailing Address
( )
Day Time Phone Number
email address:
II. Contribution Election
Yes, I elect to contribute to my Health Savings Account (HSA)
Bi - Weekly Contribution: $__________
Annual contribution $____________
No, I do not elect to participate.
Simsbury Bank Acct. No.
Routing number 011104351
III. Certification
I certify that all the information on this form is correct.
Employee’s Signature: ___________________________________________________ Date: ______________________
Return completed Enrollment Form to your Benefit Department
Employer Use
Date of Hire: / /
Effective Date: / /
Number of Paychecks
This Plan Year:
Payroll Cycle: Weekly Bi-Weekly Semi-Monthly Monthly
Pay Date of First Deduction:
/ /
Note to employer Representative: Please retain the original copy of this form for you records.
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