Health Savings Account Application

Thank you for choosing Heritage Bank for your HSA Account. For your convenience, you can fill in our online HSA application form below, (secure, encrypted transmission), or you can use the fillable PDF form and mail it to us at any of the Heritage Bank addresses provided on the form.

This gives us all the information we need to prepare your HSA Plan document and account documents. We generally process all applications within 24-48 hours of receipt, so please be watching your mail for a large, white envelope from Heritage Bank containing several documents for you to sign and return to us. Your account will be officially opened once we receive the signed paperwork back from you in the mail and your paid application fee.

We look forward to working with you, and we appreciate your business!

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Account Owner Identification Information (required by law)

It is important that we receive all of the following information to expedite the opening of your new HSA account, and to ensure that we provide you with exactly which services you desire. Thank you for the opportunity to serve your HSA needs!
Patriot Act Disclosure

Federal law requires all financial institutions to obtain, verify and record information that identifies each person who opens an account. We must ask you for certain identifying information contained herein, and because most HSA accounts are not opened in person, we must verify your identity. By checking below you authorize 1) Heritage Bank to obtain a credit bureau report for that purpose and 2) certify that all information is correct. Thank you.

Name*
Date of Birth*
Mailing Address*
Physical Address if different than above*
Issue Date*
Expiration Date*
Account Access
Name
Date of birth
Eligibility Information

According to the IRS, you are eligible to establish this HSA only if you meet the following eligibility requirements: (1) you are covered by a high deductible health plan (HDHP); (2) you are not covered by a non-HDHP; (3) you are not able to be claimed as a dependent by another taxpayer; and (4) you are not age 65 and enrolled in Medicare.
Health Plan Information - Type of health insurance coverage (check one)
Effective date of HSA-eligible high deductible health plan*
HSA contributions can be made either by the account owner or your employer or both. Please indicate your intentions below:
Please provide name of your employer.

Designation of Inheriting Beneficiary

Section 1.5 of Article VII of the Health Savings Custodial Account Agreement contains an important discussion of your right to name primary and contingent beneficiary(ies). Your designation will revoke all prior HSA beneficiary designations with respect to the referenced HSA account. In the event of your death you hereby direct that any balance in your HSA shall be paid to the following designated beneficiary or beneficiaries. If any primary or contingent beneficiary dies before you, then you wish to have the following result:
If you do not select an option above, then you are deemed to have elected the “pro rata” selection.
If you do not select an option above, then you are deemed to have elected the “pro rata” selection.

Inheriting Beneficiary(ies)

*If you wish to designate more than four primary or contingent beneficiaries, please provide a complete listing on a separate piece of paper along with your completed application.
You designate that the following person shall be your beneficiary:
Name
Address
Date of birth
You designate that the following person shall be your beneficiary:
Name
Address
Date of birth
You designate that the following person shall be your beneficiary:
Name
Address
Date of birth
You designate that the following person shall be your beneficiary:
Name
Address
Date of birth

Convenient Account Access

So that we can best serve your needs, tell us how you would like to access your account:
Would you like to order any additional cards?
Additional Services
Approval

You have requested that Heritage Bank establish a Health Savings Account (HSA) for you. You certify that you are eligible for an HSA contribution and your tax identification number (social security number) and other information are correct. In the event that this is a rollover contribution, you hereby irrevocably elect to treat this contribution as a rollover contribution. The rules and conditions governing this HSA form are contained in this application and the plan agreement. You acknowledge that the Custodian will furnish you with a copy of the application, and the HSA Plan and Disclosure Statement. You expressly acknowledge that you are responsible to determine your eligibility for this HSA and the permissibility of your contribution amount.

This field is for validation purposes and should be left unchanged.