City of Breese HSA 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 as a "Per Payroll" amount. When starting an HSA, you can make a contribution to your HSA for each month that you are eligible. For each month that you are eligible, you can contribute one-twelfth of the annual maximum for HSA contributions.

City of Breese's payroll schedule is based on 26 pay periods per year.

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 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.

Spouse
Dependent 1
Dependent 2
Dependent 3
Dependent 4
Dependent 5
Dpendent 6
Dependent 7
BENEFICIARY INFORMATION

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: bancorphsa@thebancorp.com 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 IntegraFlex Employee Portal. Instruction on how to create your online account will be listed in your IntegraFlex enrollment packet provided to you from your company's HR department. Once you have logged into your account through the IntegraFlex Employee Portal, there will be a "View Details" button to click on to be directed to your My HSA Account Information page and a Show Account # link located in the middle of the page, can be clicked on when your bank account number has been assigned. Should you need any assistance, please contact IntegraFlex Customer Service at: (208) 287-0310.

ACCEPTANCE OF TERMS

By initialing below I understand that the ANY 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 Bancorp Bank to provide IntegraFlex 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 IntegraFlex for the purpose of providing bank account summary information.

I understand The Bancorp Bank charges a monthly account maintenance fee of $2.50 that will automatically be deducted from my Health Savings Account on a monthly basis. The account maintenance fee will be waived for the first three (3) statement cycles after the account opening, and any statement cycle in which the account maintains a balance of (a) over $2,500, or (b) over $1,500, if an electronic deposit is credited to the account that statement cycle.

I understand The Bancorp Bank charges a monthly paper statement fee of $2.50 that will automatically be deducted from my Health Savings Account on a monthly basis. However, I can "Opt-In" through the IntegraFlex Employee Portal under the My HSA tab under the drop-down menu - HSA Statements, I can "Opt-In" to receive Online Statements Only and by doing so, the $2.50 fee will not be charged each month to my HSA bank account.

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

HEALTH SAVINGS ACCOUNT TRUST AGREEMENT

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, IntegraFlex 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

PLEASE READ AND SIGN TO THE FOLLOWING STATEMENT

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.

THE IRS DOES NOT REQUIRE YOUR CONSENT TO ANY PROVISION OF THIS DOCUMENT OTHER THAN THE CERTIFICATION REQUIRED TO AVOID BACKUP WITHHOLDING.

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

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