AID: HSA3357

Online HSA Application

Please complete all fields below. After clicking submit you will have a chance to review and edit your information. Once all of your information is correct, you may print out the application and fax or mail it in along with a legible copy of your driver’s license or valid ID along with your initial account funding. If you're authorizing another party as an Account Signer, please include a copy of their driver’s license as well.

Faxed applications should be sent to: 866.826.0104 (Attn: HSA Department). Mailed applications should be sent to: Falcon National Bank, Attn: HSA Dept., 1010 West St. Germain St., Suite 150, St. Cloud, MN 56301.

Online HSA Application

Part 1 — HSA Account Holder Personal Information

HSA Account Holder Personal Information

You will receive your Falcon National Bank MasterCard™, HSA checks and online banking intstructions via the US Mail.

Part 2 — Contribution Information

Contribution Information

My initial contribution will be provided:

Part 3 — Designation of Beneficiary (Optional)

Designation of Beneficiary (Optional)

Part 4 — Authorized HSA Account Signer (Optional)

Authorized HSA Account Signer (Optional)

If you want your spouse or other party to have access to your HSA please complete this section. There is no charge for adding a second signer to your account. Note: A copy of the driver's license for the Authorized Signer must be included with your application.

Part 5 — Terms & Conditions

Terms & Conditions

You must read (available anytime by clicking below or by calling 320-223-6300) and agree to the terms in the
Disclosures and Fees Brochure and the Account Terms and Conditions.