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 #:*	Date Incorporated/Organized:
Mailing Address:*	City:*		State:*		Zip:*
Street Address:	City:		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
Name:*
Title:*
Email:*	Voice:*		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.
Name of Bank:
Company Name on Account:
Bank Account #:
Routing #:
Additional Services
If you wish to add additional services check all that apply:
Section 125 Premium Only Plan
Section 125 Plan with Reimbursement Accounts
COBRA Administration
Health Reimbursement Account Administration
Form 5500 Preparation Services
Authorization

Authorized Representative Name:*
Title:*
Email:*	Voice:*		Fax: