Employer Informaon
Enrollment cannot be processed without your employer’s name.
Employer Name
Account Holder Informaon
First Name M.I. Last Name
SSN Gender
c
Male
c
Female
Date of Birth (mm/dd/yyyy)
Email Address Home Phone
( )
Physical Street Address City State ZIP
Mailing Address (if dierent) City State ZIP
Insurance Coverage
Insurance Carrier
Coverage Eecve Date Coverage Type
c
Single
c
Family
Authorizaon and Cercaon
By opening a health savings account (HSA) with HealthEquity, you accept the terms of HSA enrollment and the custodial agreement. You
may view the HSA custodial agreement here: hp://healthequity.com/en/Site/EducaonCenter/Forms.aspx by looking under Health
Account Forms and Agreements. Upon enrollment, you understand and agree to the following:
• You are covered by a qualified high deducble health plan (HDHP).
• You are not covered by any other non-qualified health coverage, including Medicare.
• You do not have access to dollars in a exible spending account (FSA) to pay for any medical expenses before the required HDHP
deducble is met, including a spouse’s FSA.
• You are not claimed as a dependent on another individual’s tax return.
• HealthEquity must verify your identy in order to open your HSA.
For further informaon regarding HSA laws, go to hp://www.irs.gov/pub/irs-pdf/p969.pdf.
Print Name Signature Date
The balances in all HealthEquity HSAs are FDIC-insured unless invested in mutual funds.
Health Savings Account (HSA)
Employee Enrollment Form
Return completed forms to your Human Resources Department.
HSA_Employee_Enrollment_Form_Return_to_ER_20140514
