ABC Company HSA / Limited-Purpose FSA Enrollment

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Note: When completing your enrollment form, it is IMPORTANT to please carefully read each text field and any notes associated with the text field. Please complete as specified. Should you have any questions, please contact IntegraFlex Customer Service at: (208) 287-0310 and one of our customer service representatives can assist you.

** Indicates Required Fields.

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Employer Information

Note: 2015/2016 IRS Maximum Contribution and Out-of-Pocket Limits for Health Savings Accounts (HSAs) and High Deductible Health Plans (HDHPs) are as follows:

HSA Annual Maximum Contributions:

- Individual: $3,350 (2015) / $3,350 (2016)
- Family: $6,650 (2015) / $6,750 (2016)
- HSA Catch-Up Contributions (Age 55 or Older): An additional annual amount of $1,000 can be contributed to the HSA Annual Maximum Contributions.

HDHP Minimum Deductible Amounts:

- Individual: $1,300 (2015) / $1,300 (2016)
- Family: $2,600 (2015) / $2,600 (2016)

HDHP Maximum Out-of-Pocker Amounts (Deductibles, Copayments, and other amounts, but not premiums):

- Individual: $6,450 (2015) / $6,550 (2016)
- Family: $12,900 (2015) / $13,100 (2016)

Note: Please specify your elections in an Annual amount. When starting an HSA, your first 12 months of contributions CANNOT exceed 1/12 per month of the Allowed Annual Maximum.

Note: Please specify your elections in an Annual amount. Limited-Purpose FSA monies can ONLY be used toward Dental and Vision Expenses. When enrolled in an HSA, your medical and prescription expenses MUST be run through your HSA account.

Employee Information

Note: Please provide us with your best contact number and email address, so we may contact you regarding your account, if needed.

Note: Your personal information and email are kept private and secure within American Health Value's and IntegraFlex's systems. We DO NOT disseminate to any Third Party's unless we have your specific written consent. We solely use your email for communication purposes regarding your benefit account(s). We will email to you correspondence such as: Quarterly Account Balance Statement, Receipt Notification Request when verification of a debit card transaction is needed, when your claim has been processed letting you know of reimbursement, etc.

Spouse/Dependent(s) Information

Note: When entering spouse and/or dependent(s) information, you MUST under IRS Rules enter their Full SSN and DOB. If this information is not provided, we CANNOT process claims for a spouse and/or dependent(s) under the Rules of the IRS.

Note: For an additional debit card for a Spouse and/or Dependent(s). Please contact IntegraFlex Customer Service to request additional cards. Dependents MUST be 18 years of age for debit card eligibility.

Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dpendent 6
Dependent 7

In the event of death, you may name a Primary Beneficiary and Secondary Beneficiary.

NOTE: PLEASE DOWNLOAD AND COMPLETE the Printable/PDF Fillable Health Savings Account Signature Card form. Please "type" your information into the form. Once complete, please print and sign the form and scan/email the HSA Signature Card to: or fax the form to: (302) 791-5771.

NOTE: Before sending the HSA Signature Card to The Bancorp, please allow at least one (1) week for your account to be set-up and a bank account number assigned to you after we have received your HSA enrollment. To obtain your bank account number, you will want to create an online account through the American Health Value Member Login Portal located on the American Health Value website. Instruction on how to create your online account will be listed in your enrollment packet provided to you from your company's HR department. Once you have logged into your account through the American Health Value Member Login Portal, you will be transported to our secure online banking platform to access your Health Savings Account. Should you need any assistance, please contact American Health Value Customer Service at: (800) 914-3248.


By initialing below I understand that the ANNUAL FEES are NON-REFUNDABLE and I apply to the institution by its signature accepts my application to establish a Health Savings Account pursuant to the terms of the Health Savings Account Agreement and Disclosure Statement, which is incorporated into this application by reference. I authorize the bank to provide American Health Value all data necessary to maintain the account. I/We authorize the transfer of information, as necessary from my/our account at The Bancorp Bank to my/our account at American Health Value for the purpose of providing bank account summary information.

I understand the American Health Value administrative fee will automatically be deducted from my Health Savings Account on an annual basis.

I understand as the account holder, I am responsible for the establishment and maintenance of this account pursuant to Federal Guidelines. American Health Value is here to assist the account holder in accomplishing this.


I acknowledge that I have reviewed the Health Savings Account Agreement and Disclosure Statement. The trustee or administrator is authorized to act without further inquiry in accordance with writings bearing my signature. I understand that I may revoke this agreement by written notice to the trustee or administrator within seven (7) days after the date of this agreement specified below

This deposit account is subject to all applicable rules and regulations adopted by The Bancorp Bank. My signature acknowledges my acceptance of the Truth in Savings Disclosure governing these accounts. The Bancorp Bank may order a consumer report from a credit reporting agency in order to evaluate whether to issue a debit card for those consumers who have applied.

I authorize my Benefit Administrator, American Health Value and/or The Bancorp Bank (Bank) to make credit and debit entries to my Checking Account/HSA Account, the Bank is the Custodian thereof, for the sole purpose of correcting any contributions that may be made in error to my Account. For purposes of this Authorization, the Bank may also be referred to as the Depository


Under penalties of perjury, I certify that:

1) The number shown on this form is my correct taxpayer identification number (TIN) or I am waiting for a number to be issued to me.
2) I am not subject to backup withholding because:
(a) I am exempt from backup withholding under Internal Revenue Service (IRS) regulations, or
(b) I have not been notified by the IRS that I am subject to backup withholding as a result of failure to report all interest or dividends, or
(c) the IRS has notified me that I am no longer subject to backup withholding, and
3) I am a U.S. person (including a U.S. resident alien).

CERTIFICATION INSTRUCTIONS - You must cross out item 2 above if you have been notified by the IRS that you are currently subject to backup withholding, because of under-reporting interest or dividends on your tax return.


By electronically signing I am signifying my understanding and acceptance of the responsibilities and requirements associated with a Section 125 and Section 223 Health Savings Account Plan. I further understand that, though I may have completed separate enrollment forms for the insurance policies to which I have applied, this enrollment does not constitute acceptance by the companies to which I have applied. Any previous agreements under any other Health Savings Account Plan are hereby revoked.

Date of Signature

Agent Information
Payment Enclosed with Application
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