Agent Login  |  HSA Member Login
Account Application Form
Enter the required information in the fields below in order to complete your online HSA Application.  Upon submission, you will receive a confirmation email with details as to how your application is being processed.
Online Payments
*Note:  All fields marked with an asterisk (*) are required.

*Note: All fields marked with an asterisk (*) are required.
*First NameMI*Last Name
*Social Security Number*Date of Birth
*Contact Email
*Mother's Maiden Name
*Mailing Address
*City
*State*Zip Code
Residential Address (if different)
City (if different)
State (if different)Zip Code (if different)
*Home PhoneWork Phone
*Employer
*Driver's License Number
*State of License
*License Expiration Date
Joint Account Holder Information:
(do not complete if you are not applying for a joint account)
First NameMILast Name
Social Security NumberDate of Birth
Referral Information:
Referral Code
Health Insurance Information:
Agent First NameAgent Last Name
*Insurance Carrier*Insurance Policy Title
*Insurance Effective Date*Insurance Deductible*Coverage Type
*Do you have co-pays for doctor's visits or prescriptions, prior to your deductible being met?
Payment Information:
A $36.00 annual administration fee and $10 opening deposit will be charged to your credit card to set up your account. Future annual administration fees will come directly from your HSA account.  Annual administration fees are non-refundable.

*Additional Opening Deposit
Acceptance of Terms:
By entering your initials below, you are indicating that you have read, understand, and agree to the terms and conditions.
*Enter Your Initials