Employee Information
Last name First name M.I.
Date of birth Social security # Employer
Mailing address City State/Zip
Street address (required) Home phone # (area code) Work phone # (area code & ext.)
Coverage for
Employee and 1 or more dependants
Plan elected
$1,500 deductible / $3,000 deductible
$2,500 deductible / $5,000 deductible
$5,000 deductible / $10,000 deductible
Maximum contribution (total of employee & employer contributions):
$3,350.00 Employee only
$6,650.00 Employee and 1 or more dependents
Catch-up contribution
An additional $1,000 catch-up contribution is allowed for participants who
are 55 and older
Do you currently have an HSA account
with Health Equity:
Yes
No
Have you had an account in previous years:
Yes
No
Employee contribution deducted per pay period:
$ __________(fixed amount pulled per pay period):
Total annual employee contribution:
$ ___________
Employer contribution per month:
$ __________ (fixed amount contributed per month):
Total annual employer contribution:
7/1/15 - 12/31/15
$ ___________
1/1/16 - 6/30/16
$ ___________
7/1/15 - 12/31/15
$ ___________
1/1/16 - 6/30/16
Number of pays contributions are pulled from yearly:
20
21
24
26 # __________ (remaining pay
periods for participants enrolling mid-year)
(This information will be used by your employer to setup a
scheduled pre-tax payroll deduction. If enrolling mid-year,
calculate total annual contribution by multiplying the salary
reduction per pay period by the remaining pay periods left
in the fiscal year.)
Total annual contribution:
$___________
APEHP will cover the administration fee for you if
you remain on an APEHP high deductible health plan.
Name Relationship Social security #
Address City State/Zip
Account Setup
Primary Beneficiary Information
Authorization and Certification
Health Savings Account (HSA) Employee
Enrollment Form
I understand that I must be covered by a qualified high deductible health plan, not covered by another health
plan including Medicare, and cannot be claimed as a dependent on another individual’s tax return.
In compliance with the USA PATRIOT Act, HealthEquity must verify the identity of all customers seeking
to open an HSA. As part of this identity verification process, you may be asked to provide additional
information and/or documentation before your account can be established.
____________________________ ___________________________________ _______________
Print name Signature Date
If you have any questions about your HSA, please call HealthEquity at (866) 346-5800.
APEHP-104-V2 Rev. 4/15
Employee only
