Health Saving Account (HSA) New Account Set-up

Which YMCA Association *

Glacial Community YMCA

YMCA of Northern Rock County

Employees Legal Name *

Social Security # *

Driver License # *

Driver License date of issue * +

Driver License expiration date * +

Phone *

Email Address *

Date of Birth * +

Occupation *

Street Address *

City *

State *

Zip Code *

PLAN INFORMATION

Plan Coverage: *

Individual

Family (Employee +1 or more

Marital Status: *

Single

Married

Primary Beneficiary Information

First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Relationship to Account Holder: *

Percentage *

Social Security Number *

Date of Birth * +

2. Primary Beneficiary Information

2 First Name

Last Name

Street Address

City

State

Zip Code

Relationship to Account Holder:

Percentage

Social Security Number

Date of Birth +

3. Primary Beneficiary Information

3 First Name

Last Name

Street Address

City

State

Zip Code

Relationship to Account Holder:

Percentage

Social Security Number

Date of Birth +

4. Primary Beneficiary Information

4 First Name

Last Name

Street Address

City

State

Zip Code

Relationship to Account Holder:

Percentage

Social Security Number

Date of Birth +

Would you like to add Contingent beneficiaries? *

Yes

No

Contingent Beneficiary Information (if any)

5 First Name *

Last Name *

Street Address *

City *

State *

Zip Code *

Relationship to Account Holder: *

Social Security Number *

Date of Birth * +

Percentage *

2. Contingent Beneficiary Information

6 First Name

Last Name

Street Address

City

State

Zip Code

Relationship to Account Holder:

Social Security Number

Date of Birth +

Percentage

3. Contingent Beneficiary Information

7 First Name

Last Name

Street Address

City

State

Zip Code

Relationship to Account Holder:

Social Security Number

Date of Birth +

Percentage

4. Contingent Beneficiary Information

8 First Name

Last Name

Street Address

City

State

Zip Code

Relationship to Account Holder:

Social Security Number

Date of Birth +

Percentage

Additional Information

Account statement delivery: *

Mail (Paper)

E-mail (Paperless)

On-line access to view account? *

Yes (email required)

No

Debt card will be issued. Would you also like checks for additional charge *

Yes

No

If others are to have access to the account with a debit card or writing checks, please include their information below.

Do you want to add other individuals to have access to your account? *

Yes

No

Full Legal Name *

Social Security # *

Driver License # *

Driver License date of issue * +

Driver License expiration date * +

Date of Birth * +

Occupation *

Street Address *

City *

State *

Zip Code *

Deposit amount and signature

Amount to deposit per pay check: (If less than $50, opening deposit will be $50 & subsequent deposits will be as requested). *

Amount to deposit per pay check: (If less than $100, opening deposit will be $100 & subsequent deposits will be as requested). *

Effective date: +

I hereby authorize Glacial Community YMCA to make pre-tax deduction from my payroll and contribute those funds to my health savings account. This deduction will remain in effect unless I choose to make changes on my Paycor profile found under direct deposits. *

Yes (If no please contact HR)

I hereby authorize the YMCA of Northern Rock County to make pre-tax deduction from my payroll and contribute those funds to my health savings account. This deduction will remain in effect unless I choose to make changes on my Paycor profile found under direct deposits. *

Yes (If no please contact HR)

Signature *

clear

Date * +