Employer Forms
Whatever the situation, we have the forms to assist you.
Employer Forms
Employer Information
This form provides us with basic information on the employer (name, contact person, type of plan) and is designed to be used by employers that are not utilizing the HSA Admin Center. To enroll in the HSA Admin Center click here.
Employer Contribution Worksheet
For employers that are not using the HSA Admin Center and wish to make contributions to employee HSAs. Use this form (or your own) to provide us with a breakdown of the contribution between individual employees. This form may also be used to add or remove employees.
Employer Contribution Worksheet
PDF version of the Employer Contribution Worksheet.
HSA Application for Groups
Use this application to open your HSA with HSA Resources. Note: use this Application for only if you are participating in an employer HSA plan.
Transfers and Rollovers
Use this form to transfer an HSA/MSA/FSA/HRA from another administrator. If you have already closed your HSA with the other administrator and received a check, please use the HSA Contribution Form.
ACH Agreement
For employers that will be conducting regular ACH transfers to fund their employees’ HSAs.
HSA Payroll Deferral Election Form
If you allow employees to do deferrals through payroll, the employee will need to tell you the amount of the deferral. Use this form to obtain employee elections. Note: often, your Section 125 plan provider supplies a form for this purpose.
Employee Forms
Change of Beneficiary
Complete this form to identify who you would like to inherit your HSA or to change your beneficiaries. Note: if you designate your spouse, your HSA will transfer tax free and become your spouse’s HSA.
HSA Contribution Form
To make additional contributions to your HSA please complete, sign and submit this form along with your contribution. Note: you may check your total contribution limit with our HSA Contribution Worksheet.
HSA Distribution Form
If you would like to take a distribution to pay for a medical expense and do not want to use your checking account or Falcon National Bank MasterCard™, you may also submit a completed Distribution form.