Health Savings Account Application, Part 2

Thank you for starting your application for a Health Savings Account (HSA) with Bank Midwest! We need to ask you a few more questions.

Please note that HSA accounts have a monthly service charge of $1.25 and the interest rate will automatically change according to the balance in your account.

Step 1 of 3

Applicant Details
First, let's reconfirm your name and email.
Name * Required
First Last
Email * Required
Eligibility
Next, we need to make sure you're eligible to open an Health Savings Account which can only be used with qualified high-deductible insurance plans. If you cannot verify the following statements, you may not be eligible to open this account. Call 888.902.5662 if you have any questions.
I verify * Required
- I am eligible to establish a Health Savings Account.
I verify * Required
- I am or will be covered by a qualified High Deductible Health Plan (HDHP).
I verify * Required
- I am not covered under any other health plan that is not compatible with a Health Savings Account.
I verify * Required
- I am not enrolled in Medicare.
I verify * Required
- I may not be claimed as a dependent on another person's tax return.
What type of health plan coverage do you have? * Required
- Family Plan
- Single Plan
What is the effective date of your health insurance? * Required
Month
Day
Year

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Beneficiaries
You're almost done! Finally, please share the names of any beneficiaries to be listed for your HSA account.
How many primary beneficiaries would you like to designate? * Required
I designate that the assets in this account be paid to the beneficiaries named below upon my death. The interest of any beneficiary that predeceases me terminates completely, and the share of any remaining beneficiaries will be increased on a pro rata basis.
- 0
- 1
- 2
- 3
- 4
No Beneficiary Designations * Required
- I elect not to designate beneficiaries at this time and understand that I may designate beneficiaries at a later date.
If you do not designate personal beneficiaries, your estate will be your beneficiary.
Beneficiary #1 * Required
First Last
Is Beneficiary #1 your spouse?
- Yes
- No
Beneficiary #1 Address * Required
Street Address Address Line 2 City State ZIP Code
Beneficiary #1 Phone * Required
Beneficiary #1 Percent Designation
Please enter a number from 1 to 100.
The total primary designation should total 100%. If multiple beneficiaries are names but designations left blank, the beneficiaries will be deemed to own equal share percentages in the HSA.
Beneficiary #2 * Required
First Last
Beneficiary #2 Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Beneficiary #2 Phone * Required
Beneficiary #2 Percent Designation * Required
Please enter a number from 1 to 100.
The total primary designation should total 100%. If multiple beneficiaries are names but designations left blank, the beneficiaries will be deemed to own equal share percentages in the HSA.
Beneficiary #3 * Required
First Last
Beneficiary #3 Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Beneficiary #3 Phone * Required
Beneficiary #3 Percent Designation
Please enter a number from 1 to 100.
The total primary designation should total 100%. If multiple beneficiaries are names but designations left blank, the beneficiaries will be deemed to own equal share percentages in the HSA.
Beneficiary #4 * Required
First Last
Beneficiary #4 Address * Required
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code
Beneficiary #4 Phone * Required
Beneficiary #4 Percent Designation
Please enter a number from 1 to 100.
The total primary designation should total 100%. If multiple beneficiaries are names but designations left blank, the beneficiaries will be deemed to own equal share percentages in the HSA.
Would you like to designate contingent beneficiaries? * Required
By listing contingent beneficiaries, the balance in your HSA account will be payable to these beneficiaries if all primary beneficiaries have predeceased you or the joint HSA owner.
- Yes
- No
How many contingent beneficiaries would you like to designate? * Required
I designate that the assets in this account be paid to the beneficiaries named below upon my death. The interest of any beneficiary that predeceases me terminates completely, and the share of any remaining beneficiaries will be increased on a pro rata basis.
- 1
- 2
- 3
- 4
Contingent Beneficiary #1 * Required
First Last
Contingent Beneficiary #1 Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Contingent Beneficiary #1 Phone * Required
Contingent Beneficiary #1 Number
Please enter a number from 1 to 100.
Contingent Beneficiary #2 * Required
First Last
Contingent Beneficiary #2 Address * Required
Street Address Address Line 2 City State ZIP Code
Contingent Beneficiary #2 Phone * Required
Contingent Beneficiary #2 Percent Designation
Please enter a number from 1 to 100.
Contingent Beneficiary #3 * Required
First Last
Contingent Beneficiary #3 Address * Required
Street Address Address Line 2 City State ZIP Code
Contingent Beneficiary #3 Phone * Required
Contingent Beneficiary #3 Percent Designation
Please enter a number from 1 to 100.
Contingent Beneficiary #4 * Required
First Last
Contingent Beneficiary #4 Address * Required
Street Address Address Line 2 City State ZIP Code
Contingent Beneficiary #4 Phone * Required
Contingent Beneficiary #4 Number
Please enter a number from 1 to 100.
Comments
This field is for validation purposes and should be left unchanged.

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Health Savings Account, Part 2

Step 1 of 3

Applicant Details

Eligibility

Contribution Information

Deposit Details

Beneficiaries