Get Employer Offered Hsa (program Offered Through Employer) - Employer Name

Completing the Employer Offered HSA form online is an essential step for users who wish to establish a health savings account through their employer. This guide provides clear, step-by-step instructions to help users accurately fill out the form and ensure all necessary details are included.

Follow the steps to fill out your Employer Offered HSA form online.

1. Click ‘Get Form’ button to access the Employer Offered HSA form, and open it for editing.
2. Provide your account holder's information in the designated fields. Enter your last name, first name, middle initial, street address, city, state, zip code, email address, primary phone number, social security number, and date of birth.
3. In the health insurance plan information section, if you are participating in the employer-offered HSA, skip the HSA plan type selection. If you are completing the form for an Individual HSA, select the appropriate plan type: Thrift, Basic, or Premium.
4. Indicate the effective date of your health insurance plan in the relevant field.
5. For electronic deposits of contributions and withdrawals, provide your bank information. Specify whether it is a checking or savings account, and fill in the bank name, phone number, ABA routing number, and account number.
6. State the amount to be pulled from your bank account for HSA contributions and select the frequency—either monthly or one time only.
7. Sign and date the form, confirming your eligibility to establish the HSA for qualified medical expenses.
8. If applicable, fill out the beneficiary designation. If you have a spouse, they will automatically be designated as your beneficiary.
9. Review all the information for accuracy and completeness.
10. Finally, save changes to the form, and download, print, or share it as necessary before returning it to your employer.

Complete your Employer Offered HSA application online today!