HSA Enrollment Form

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All fields marked with * are required.

Health Savings Accounts

Thank you for your interest in opening a Health Savings Account with First National Bank. You're on the road to saving for your future health care costs and saving for retirement. If you have any questions about HSAs or completing this form, please contact our Customer Service Center, we would be glad to assist.

PART I - CONTACT INFORMATION

Applicant Name *

Street Address *

City *

State *

Zip Code *

Phone Number *

Email Address *

Name of Employer *

Employer Address *

PART II - VERIFICATION OF ELIGIBILITY

According to the IRS rules, only qualified individuals are eligible to open a Health Savings Account. Please read the following information and then check the box to confirm your eligibility.

* Are covered under a qualifying high-deductible health plan which meets the minimum deductible and the maximum out-of-pocket threshold for the year.

* Are not covered by any other medical plan, such as a spouse’s plan.

* Are not enrolled in Medicare.

* Are not claimed as a dependent on someone else’s tax return.

* Have not used Veterans Administration medical benefits in the past three months (exceptions apply to veterans enrolled in a high-deductible health plan who either have a service-connected disability or have only accessed disregarded coverage and preventive services in the past three months.

* Do not have any disqualifying alternative medical savings accounts, like a Flexible Spending Account or Health Reimbursement Account.

Eligibility Confirmation *

Eligible
Not Eligible
Unsure

PART III - INSURANCE COVERAGE

To be eligible for an HSA, you must be enrolled in a High-Deductible Health care Insurance Plan. Please respond to the questions below about your insurance coverage.

Name of Insurance Provider *

Coverage Effective Date *

Coverage Type

Single Plan
Family Plan

FINAL STEPS

You are making excellent progress toward the opening of your HSA and are on your way to benefitting from its triple-tax advantages. A Relationship Banker will be contacting you to finalize any details about your HSA, including:

1) Beneficiary Designation. Another benefit of having an HSA is that if you accumulate more money than you need in your account, the unused funds will go to your beneficiary when you die. The named beneficiary(ies) determines how your HSA money is handled after you die.

2) Identity Verification. Examples of acceptable identity verification documents include:

* For address verification: A driver's license, state identification, bank statement, or a current phone or utility bill displaying the input address. Note: You must use your residential address, not a P.O. Box.

* For a Social Security number: A social security card.

* For date of birth: A driver's license, U.S. passport, birth certificate, or state identification.

* For name validation: A social security card, passport, birth certificate, divorce decree, legal name change certificate, or state identification.

Once details are finalized, you can sign documents electronically through DocuSign or in-person at a First National Bank location.

Thanks for selecting First National Bank as place to service your financial needs. You will hear from us soon!

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