Company Application


 


HSATODAY Employer Information & Funding Form
General Information
*Indicates Required Field
Entity Name:* Enter name exactly as it appears on tax returns and is to appear in the documents.
Federal Tax ID #:*
State:*
Zip:*
Number of eligible employees: *

Effective Date of HSA: *


Effective Date of Insurance Renewal: *
 
Organization Type: "C" Corporation Sub-Chapter "S" Corporatiion
  Non-Profit Organization LLC Limited Liability Company 
  Partnership Sole Proprietorship
  Government Agency Other
Employer Primary Contact

Fax:

HSA Funding Method - please check all that apply and complete
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.  
Routing #: 
Additional Services
If you wish to add additional services check all that apply:
Authorization
 
 
Title:*