Kereon HSA - Open an HSA

Guidelines to Open an HSA
Download the “HSA Application and Custodial Agreement ” form. 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.
Forms to Submit Online or Download	What Else?
• HSA Application and Custodial Agreement • Transfer Current HSA to Kereon HSA • IRA Transfer to Kereon HSA	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.
Taking Care of You is our Number One Priority
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.


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