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Guidelines to Open an
HSA |
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- Fill out the “Account
Holder Information” section
including your name and contact information.
- If you are applying for an HSA through your
work place, please fill out the “Employer Information” section.
- Complete the “Eligibility Information” section
to determine your HSA eligibility.
- Fill out the “High Deductible Health Plan” (HDHP)
section. To be eligible for an HSA, you must be covered by a high
deductible health plan.
- Fill out the “Primary Beneficiary” and “Contingent
Beneficiary” sections. This person will inherit your HSA upon
your death. If no one is listed, the account will transfer to your
estate.
- Fill out the “Electronic Funds Transfer ” section
to authorize transfers between your personal bank account and your
HSA.
- Sign, date and send the HSA Application and Beneficiary
Designation form along with your check for $88 ($63 annual administration
fee including smart debit card plus an initial $25 one time only, administration set up fee) to Kereon HSA, Inc.
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What
Else?
Before
completing the HSA Application and Beneficiary Designation Form, carefully
read the HSA Custodial Account Agreement which includes the Disclosure
Statement, Terms and Conditions and the Privacy Protection Notice. |
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 • HSA Application and Custodial Agreement
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Transfer Current HSA to Kereon HSA
•
IRA Transfer to Kereon HSA |
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We
make it easy for you. Fill out the HSA Application and Beneficiary
Designation Form, then return it to Kereon HSA via fax or mail. The
fax and address are on the back of the application. Kereon HSA (your
Plan Service Provider) will then forward your application to the Custodian
to establish your Health Savings Account. |
