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HSA Application

Complete this application to open your new HSA.

* Required

*Employer Name

HSA Type

HSA Checking

HSA Savings

Account Information

*First Name

Middle Name

* Last Name

*Email Address

*Phone Number

*Social Security Number

*Driver's License #

*License State

*License Issue Date

*Licene Expiration Date

*Street Address (P.O. Box not allowed)

*City

*State

*Zip Code

*Status

Renting

Own

*Years at Residence

*Date of Birth

Designation of Beneficiary

At the time of my death, the primary beneficiaries named below will receive my HSA assets. If all of my primary beneficiaries die before me, the contingent beneficiaries named below will receive my HSA assets. In the event a beneficiary dies before me, such beneficiary's share will be reallocated on a pro-rata basis to the other beneficiaries that share the deceased beneficiary's classification as a primary or contingent beneficiary. A designation of a beneficiary's primary or contingent classification is generally made by entering a percentage in one of the two columns to the left of the name. In the event a beneficiary is named as both a primary and contingent beneficiary, or if a beneficiary is not assigned to a beneficiary classification, such beneficiary shall be a primary beneficiary. If no percentages are assigned to beneficiaries, or if the percentage total for any beneficiary classification exceeds 100 percent, the beneficiaries in the classification will share equally. If the percentage total for each beneficiary is less than 100 percent, any remaining percentage will be divided equally among the beneficiaries within such class. If all of the beneficiaries die before me, or if none are designated, my HSA assets will be paid to my estate. This designation revokes and supercedes all earlier beneficiary designations which may apply to this HSA.

Beneficiary 1

Primary Share %

Contingent Share %

Name of Beneficiary

SSN or TIN

Relationship

Date of Birth

Street Address

City

State

Zip Code

Beneficiary 2

Primary Share %

Contingent Share %

Name of Beneficiary

SSN or TIN

Relationship

Date of Birth

Street Address

City

State

Zip Code

Beneficiary 3

Primary Share %

Contingent Share %

Name of Beneficiary

SSN or TIN

Relationship

Date of Birth

Street Address

City

State

Zip Code

Beneficiary 4

Primary Share %

Contingent Share %

Name of Beneficiary

SSN or TIN

Relationship

Date of Birth

Street Address

City

State

Zip Code

Community or marital property state laws may require spousal consent for a nonspouse beneficiary designation. The laws of the state in which the financial organization is domiciled, the HSA owner resides, the trust is located, the spouse resides, or this transaction is consummated should be reviewed to determine if such a requirement exists. Spousal consent for the beneficiary designation may also be required by financial organization policy.

I Am Married. I understand that if I designate a primary beneficiary other than my spouse, my spouse must consent by signing below.

I Am Not Married. I understand that if I marry in the future, I must complete a New Designation of Beneficiary form, which includes the spousal consent documentation.

Agreement

*Do you authorize Mid American Credit Union to share your account information with your employer for the purpose of setting up and maintaining direct deposits into your account?

Yes

Note: By selecting 'No', you will be responsible for communicating necessary account information to your employer.

*Account Owner Signature

*Date

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Success!

Your application has been submitted. You will receive an email from a Mid American representative within the next 48 hours to complete your online application.