HSATODAY Employer Information & Funding Form
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General Information
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*Indicates Required Field
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Entity Name:*
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Enter name exactly as it appears on tax returns and is to appear in the documents.
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Federal Tax ID #:*
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State:*
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Zip:*
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Number of eligible employees: *
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Effective Date of HSA: *
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Effective Date of Insurance Renewal: *
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Organization Type: |
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"C" Corporation
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Sub-Chapter "S" Corporatiion
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Non-Profit Organization |
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LLC Limited Liability Company
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Partnership
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Sole Proprietorship
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Government Agency
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Other |
Employer Primary Contact
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Fax:
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HSA Funding Method - please check all that apply and complete
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All contributions to HSA's and administrative fees will be funded by ACH draft initiated by Benefit Solutions, Inc.. Benefit Solutions, Inc. will draft funds from the following Employer Bank account. Please complete bank section below.
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Routing #:
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Additional Services
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If you wish to add additional services check all that apply:
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Authorization
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Title:*
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