Coast Real Estate Services 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.

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Employer Information

Note: 2018/2019 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: $3,450 (2018) / $3,500 (2019)
- Family: $6,900 (2018) / $7,000 (2019)
- 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: $1,350 (2018) / $1,350 (2019)
- Family: $2,700 (2018) / $2,700 (2019)

HDHP Maximum Out-of-Pocket Amounts (Deductibles, Co-payments, and other amounts, but not premiums):

- Individual: $6,650 (2018) / $6,750 (2019)
- Family: $13,300 (2018) / $13,500 (2019)

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.

Coast Real Estate's payroll schedule is based on "24" pay periods per year.

To calculate your "Per Payroll" Contribution simply divide your Annual Election Contribution by "24."

REDIRECTION INFORMATION: PLEASE READ AND INITIAL THE FOLLOWING STATEMENT

By electronically signing the salary redirection form I am signifying my understanding and acceptance of the responsibilities and requirements associated with a Section 125 Cafeteria Plan. I further understand that, though I have completed separate enrollment forms for the insurance policies to which I have applied, this form does not constitute acceptance by the companies to which I have applied. I understand and agree that an amount equal to what I have calculated will be deducted from each of my qualified pay periods from now through the end of the plan year. This amount shall continue for each pay period unless this agreement is amended or terminated. I understand the actual amount of my take home pay may increase or decrease depending upon the coverage or elections I have made. Any previous agreements under any other Flexible Benefits/Cafeteria Plan are hereby revoked.

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
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 a U.S. person (including a U.S. resident alien).

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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