Note: I understand my Health Savings Account (HSA) will be set up effective
the first day of the month following the date this worksheet is signed.
HDHP Coverage Level
Single / Family
Health Savings Account (HSA) Data Collection Worksheet
Please complete and submit this worksheet to your employer. This is an internal document used by your employer for data
collection purposes. Worksheets submi�ed to Discovery Benefits will not be processed.
Step 1: Account Holder Information
Step 2: HSA Election for Current Tax Year
Step 3: Authorized Signature
*Employer Name (Do not abbreviate)
*Account Holder Name (First, MI, Last)
*Employee ID Number
*Social Security Number
*Physical Address (Cannot be PO Box)
*Date of Birth (mm/dd/yyyy) *Hire Date (mm/dd/yyyy)
866-451-3399 · 866-451-3245
PO Box 2926 · Fargo, ND 58108-2926
(to be deducted each pay period) (mm/dd/yyyy)
*Per Pay Period Amount:
Employer Contribution: Check with your employer to determine if you will
receive employer contributions. Both employee and employer contributions
will be applied to your annual IRS maximum.
Note: There may be tax consequences if HSA contributions exceed the IRS
governed limit. To determine the maximum HSA contribution for the current
tax year visit www.discoverybenefits.com.
*HDHP Coverage Date:
By signing this application I represent that: 1) I am covered under a high deductible health plan (HDHP); 2) I am not covered by any
other health plan that is not an HDHP; 3) I am not enrolled in Medicare; 4) I cannot be claimed as a dependent on another person’s tax
return; and 5) I have read and agreed to the HSA Custodial Agreement and Disclosure Statement. I understand that if my spouse is
enrolled in a general-purpose FSA (a non-HDHP), I am not eligible to contribute to an HSA. I understand my Health Savings Account
will be set up effective the first day of the month following the date the Enrollment Application is signed. Further, I understand that
my Health Savings Account cannot be effective prior to my HDHP coverage date.
*Signature of Account Holder *Date
Open Enrollment 2018
Return completed form to Human Resources by October 27 deadline:
Ask HR form | Fax: (608) 263-5778