• Step One: Complete the application below.
  • Step Two: You will be contacted within 48 hours by a Customer Associate to set up an appointment and finalize your account.
  • Step Three: Visit your nearest branch to finish opening your account.

Health Savings Account Information

Type of Health Insurance Plan Coverage:

 
 

Anticipated Opening Balance

Example: $125.00

Applicant Information

(ie favorite sport, color)
Physical Address*
Mailing address (if different)

Please answer at least 3 of the following questions to help protect you and your information from potential unauthorized individuals.

Will there be an Authorized Signer?
 
 
Physical Address
Mailing address (if different)

Please answer at least 3 of the following questions to help protect you and your information from potential unauthorized individuals.

 

Beneficiary Information

Designation of Beneficiary

An authorized signer’s access to the account ceases upon death, therefore, the Bank requires a beneficiary to be named. If your spouse is listed as your sole primary beneficiary, the HSA will become your spouse's HSA upon death.

Physical Address*
Mailing address (if different)
Beneficiary Type