HSA Application

  • OK Election Year is required

  • Are you a new customer?

    OK Are you a new customer? is required

  • I certify that I am covered by a high deductible health plan (HDHP); I am not covered by a health plan that is not a HDHP and that provides coverage for any benefit which is covered under the HDHP; I am not enrolled in Medicare; and I may not be claimed as a dependent on another person's tax return.

    OK You must choose an option

Health Plan Coverage Type

  • Type of Coverage

    OK You must make a selection

Personal Information

  • OK First Name is required
  • Optional OK Middile Name is required
  • OK Last Name is required
  • OK Social Security Number is required

  • Date of Birth

    OK Date of Birth is required
  • OK Home Phone is required
  • OK Daytime Phone is required
  • OK Mother's Maiden Name is required
  • OK Email is required
  • OK Occupation is required
  • OK Employer is required
  • OK How would you prefer to be contacted? is required
  • OK What is the best time to arrange an appointment? is required
  • OK Driver's License Number is required
  • OK State of Issue is required

  • Issue Date

    OK Issue Date is required

  • Expiration Date

    OK Date must be in the future
  • OK Choose a location you would like to complete your application. is required

Address Information

  • OK Residential Address (Not a P.O. Box) is required
  • OK City is required
  • OK State is required
  • OK Zip is required

  • Use residential address for mailing address

    OK Use residential address for mailing address is required
  • OK Mailing Address (if different than above) is required
  • OK City is required
  • OK State is required
  • OK Zip is required
  • OK Beneficiary is required
  • OK Beneficiary SSN is required
  • OK Beneficiary DOB (mm/dd/yyyy) is required
  • OK Beneficiary physical address is required
  • OK Percentage of benefits is required
  • OK Relationship to Applicant is required

Authorized Signer Info

  • Number of Additional Authorized Signers on this Account

    OK Number of Additional Authorized Signers on this Account is required

Authorized Signer #1

  • OK Relationship to Primary Applicant is required
  • OK Name is required

  • Date of Birth

    OK Date of Birth is required
  • OK Social Security Number is required
  • OK Drivers License Number is required
  • OK State Licensed Issued is required

  • Issue Date

    OK Issue Date is required

  • Expiration Date

    OK Date must be in the future
  • OK Home Phone is required
  • OK Work Phone is required
  • OK Residential Address is required
  • OK City is required
  • OK State is required
  • OK Zip is required
  • OK Employer is required
  • OK Occupation is required
  • OK Election Year is required
  • OK Beneficiary is required

Authorized Signer #2

  • OK Relationship to Primary Applicant is required
  • OK Name is required

  • Date of Birth

    OK Date of Birth is required
  • OK Social Security Number is required
  • OK Drivers License Number is required
  • OK State License Issued is required

  • Issue Date

    OK Issue Date is required

  • Expiration Date

    OK Expiration Date is required
  • OK Home Phone is required
  • OK Work Phone is required
  • OK Residential Address is required
  • OK City is required
  • OK State is required
  • OK Zip is required
  • OK Employer is required
  • OK Occupation is required
  • OK Election Year is required
  • OK Beneficiary is required

Comments

  • Optional OK is required

Security Code

  • OK is required

    Home Bank reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, you grant full permission to do so.