HSA_Enrollment_Form_2020.1 Page 1 of 3
Health Savings Account Enrollment Form
If you have any questions about HSAs or completing this form, please contact Customer Service at (603) 647-1147 ext.1.
Part I - Accountholder Profile Information
*Consumer Name (First, MI, Last) *Employer Name (If sponsored by an employer plan)
*Birth Date (MM/DD/YYYY) *
*Home Phone *Mobile Phone
*Physical Street Address (U.S. address required to open an HSA)
*City *State *Zip
Alternate Mailing Street Address or PO Box
City State Zip
*Email Address *Date of Birth
*Gender Male Female Unspecified *Marital Status Married Single
*Mother’s Maiden Name
*Hire Date *Hours Worked per Week *Payroll Frequency
Part II - Authorization and Eligibility Certification
When opening an HSA with HRC Total Solutions, I understand and agree to the following:
• I am at least 18 years old and cannot be claimed as a dependent on someone else’s tax return.
• I am covered under a high deductible health plan (HDHP).
• I am not enrolled in Medicare.
• I do not have any other non-qualified health coverage.
• I do not have a flexible spending account (FSA) to pay for medical expenses incurred before my medical
plan deductible is met, unless it is limited to pay for dental and vision expenses only.
• My spouse, if applicable, does not have a flexible spending account (FSA) to pay for medical expenses
before their medical plan deductible is met, unless it is limited to pay for dental and vision expenses only.
As a follow-up to this application, you will need to login to the HSA website to accept your terms and conditions.
*Signature *Print Name *Date