Health Savings Account (HSAs)

Open Your Account

  1. Personal Information
  2. Identity Verification
  3. Opening Deposit

Secure Form

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Confirm Information

Please confirm this information before continuing. We'll use this information to help verify your identity.

Verify

Please answer the following questions to help us verify your identity. All questions must be answered within 10 minutes.

Fund Your Account

Now you'll setup your deposit into your new account. This money will be deposited once your new account is approved.

Thank You!

We are currently verifying your application. Here's what to expect next:

    Applicant Information

Eligibility

    To open an HSA account, you must confirm your eligibility below before proceeding.

    OK By checking this box, I certify that I am covered by a High Deductible Health Plan (HDHP). is required
    OK By checking this box, I certify that I am not enrolled in Medicare. is required
    OK By checking this box, I certify that I am not covered under any other insurance plans that are not HDHP. is required
    OK By checking this box, I certify that I cannot be claimed as a dependent on someone else's tax return. is required
  • Please enter the code to confirm your ability to view the required Portable Document Format (PDF) files. If the code isn't visible, click here to see code in new window or visit your nearest branch to apply for an account.

  • OK Error - Please enter the code to verify that you can view the required Portable Document Format (PDF) files. If the code isn't visible you will need to visit your nearest branch to apply for an account.

Basic Info

  • OK First Name is required
  • OK Last Name is required
  • OK Email Address is required
  • OK Phone is required
  • OK Date of Birth is required
  • OK Social Security Number is required

Address

  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required
    OK Mailing address is different (Optional) is required

Mailing Address

  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required

Previous Address

  • Have you lived at this address for less than 2 years?

    OK You must select one of the following.
  • OK Previous Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required

Identification

  • What form of ID would you prefer to use?

    OK What form of ID would you prefer to use? is required
  • OK License Number is required
  • OK State is required
  • OK Expiration Date is required
  • OK Passport Number is required
  • OK Expiration Date is required

Tax Status

    OK Please select one of the following.
  • What is this?

    If you have any questions about how to complete this section please download instructions.

Additional Information

    For an HSA account, you will be required to receive E-Statements.

    OK By checking this box, I confirm I understand that I will be required to receive E-Statements for this account. is required
  • Would you like an HSA debit card for this account?

    OK Would you like an HSA debit card for this account? is required
  • OK Mother's Maiden Name is required
  • OK Employer Name is required
  • OK Employer Phone Number is required
  • To better serve you, please select the branch office that you would like to consider your home branch office.

    OK To better serve you, please select the branch office that you would like to consider your home branch office. is required
  • If you are designating a beneficiarie(s) on your account, please check the box(es) below and provide their name and date of birth in the spaces provided.

    OK Beneficiary No. 1 is required
  • OK Name is required
  • OK Date of Birth is required
  • (optional) OK Social Security Number is required
    OK Beneficiary No. 2 is required
  • OK Name is required
  • OK Date of Birth is required
  • (optional) OK Social Security Number is required
    OK Beneficiary No. 3 is required
  • OK Name is required
  • OK Date of Birth is required
  • (optional) OK Social Security Number is required
  • SINCE REGULATIONS REQUIRE THAT ONLY ONE INDIVIDUAL OWNS THE HSA, THE ACCOUNT HOLDER MAY WANT TO APPOINT AN AGENT/AUTHORIZED SIGNER T0 HAVE ACCESS AND TRANSACT BUSINESS ON THE HSA. I (ACCOUNT HOLDER) HEREBY DESIGNATE THE FOLLOWING INDIVIDUAL AS AN AUTHORIZED SIGNER ON MY HSA. BY DESIGNATION THE FOLLOWING INDIVIDUAL AS MY AUTHORIZED SIGNER ON MY HSA , I AUTHORIZE THAT INDIVIDUAL TO TRANSACT BUSINESS , SUCH AS, BUT NOT LI MITED TO, MAKE DEPOSITS, WITHDRAWAL, WRITE CHECKS, USE DEBIT CARD, IF APPLICABLE, AND RECEIVE ACCESS TO ACCOUNT INFORMATION BY ANY MEANS ACCEPTABLE TO THE BANK. AUTHORIZED SIGNERS MAY NOT CLOSE OR AMEND THE HSA. I INDEMNIFY AND HOLD THE BANK HARMLESS FROM AND AGAINST ANY CLAIMS, ACTIONS, LOSSES, DAMAGES, COSTS, INCLUDING REASONABLE ATTORNEYS FEES, THAT THE BANK MAY SUFFER RELATED TO AND/ OR ARISING FROM THE BANKS RELIANCE ON THIS AUTHORIZATION AND THE ACTIONS OF MY AUTHORIZED AGENT. I UNDERSTAND THAT I BEAR SOLE RESPONSIBILITY FOR ANY TAX CONSEQUENCES THAT RESULT FROM ANY ACTIONS EXERCISED BY MY AUTHORIZED SIGNER REGARDING MY HSA.

  • Will there be authorized signers on this account?

    OK Will there be authorized signers on this account? is required
    OK Authorized Signer No. 1 is required
  • OK Name is required
  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zipcode is required
  • OK Date of Birth is required
  • OK Social Security Number is required
  • OK Driver's License is required
  • OK Phone is required
    OK Authorized Signer No. 2 is required
  • OK Name is required
  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zipcode is required
  • OK Date of Birth is required
  • OK Social Security Number is required
  • OK Driver's License is required
  • OK Phone is required
    OK Authorized Signer No. 3 is required
  • OK Name is required
  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zipcode is required
  • OK Date of Birth is required
  • OK Social Security Number is required
  • OK Driver's LIcense is required
  • OK Phone is required
    OK Authorized Signer No. 4 is required
  • OK Name is required
  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zipcode is required
  • OK Date of Birth is required
  • OK Social Security Number is required
  • OK Driver's License is required
  • OK Phone is required
  • Will the authorized signers need a debit card for the account?

    OK Will the authorized signers need a debit card for the account? is required
  • Is this a Single or Family HSA plan?

    OK Is this a Single or Family HSA plan? is required

Joint Applicant

  • Will this be a joint account?

    Optional OK Will this be a joint account? is required

Co-Applicant Basic Info

  • OK First Name is required
  • OK Last Name is required
  • OK Email is required
  • OK Phone is required
  • OK Date of Birth is required
  • OK Social Security Number is required

Co-Applicant Address

  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required
    Optional OK Mailing address is different is required

Co-Applicant Mailing Address

  • OK Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required

Co-Applicant Previous Address

  • Have you lived at this address for less than 2 years?

    OK You must select one of the following.
  • OK Previous Address is required
  • OK City is required
  • OK State is required
  • OK Zip Code is required

Co-Applicant Identification

  • What form of ID would you prefer to use?

    OK What form of ID would you prefer to use? is required
  • OK License Number is required
  • OK State is required
  • OK Expiration Date is required
  • OK Passport Number is required
  • OK Expiration Date is required

Co-Applicant Tax Status

    OK Please select one of the following.
  • What is this?

    If you have any questions about how to complete this section please download instructions.

    Important Information About Procedures for Opening a New Account:

    To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.