Whatever the situation, we have the forms to assist you.
Employer Forms
Employer Information [PDF]
This form provides us with basic information on the employer (name, contact person, type of plan) and is designed to be the first form completed by the employer.
Employer Contribution Worksheet[Excel][PDF]
For employers contributing to employee HSAs. Use this form (our your own) to provide us with a breakdown of the contribution between individual employees. Use this form to add and remove employees also.
HSA Application [PDF]
Use this application to open your HSA with HSA Resources. Note: if you are participating in an employer plan, you can skip Section 2 as that information will be provided by your employer.
Transfers and Rollovers [PDF]
Use this form to transfer an HSA/MSA/FSA/HRA from another administrator. If you have already closed your HSA with the other administrator and received a check, please use the HSA Contribution Form.
ACH Agreement [PDF]
For employers that will be conducting regular ACH transfers to fund their employees' HSAs.
Employee Forms
Change of Beneficiary [PDF]
Complete this form to identify who you would like to inherit your HSA or to change your beneficiaries. Note: if you designate your spouse, your HSA will transfer tax free and become your spouse's HSA.
HSA Contribution Form [PDF]
To make additional contributions to your HSA please complete, sign and submit this form along with your contribution. Note: check your total contribution limit with our Contribution Worksheet [PDF].
HSA Distribution Form [PDF]
If you would like to take a distribution to pay for a medical expense and do not want to use your checking account or debit card, you may also submit a completed Distribution form.
