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HSA Account Application and Benefits

Across
Complete the entire form. Be sure to see the note after question
Customer Benefit
Customer Benefit
Type of Health Insurance plan Coverage
Spousal Consent
Contribution Information
Customer Benefit
This form to complete if customer wants to access their account online
Down
Choose a primary and/ or a Contingent beneficiary
Contribution Information
HSA contributions and earnings may be _______
Spousal Consent