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Employer HSA Program Set-Up Form

When you complete the Employer Set-Up Form, you're taking the first step in setting up your Health Savings Account (HSA) program.

Within three (3) business days of submitting the form, you will be contacted by a dedicated Implementation Specialist to guide you through our simple implementation process and provide log in instructions to the U.S. Bank Healthcare Payment Solutions Employer Portal. Our Employer Portal provides secure access to efficiently manage your HSA enrollment and contribution processes. If you have any questions, please contact one of our Employer Specialists at 800-334-9207.

We look forward to working with you to provide your employees with the premier HSA experience in the marketplace. It's a new day in healthcare with U.S. Bank!

All fields are required unless specified as "optional."

Employer Information:
Employer Name:
SIC Code or Industry: (optional)
Employer Address:
Employer City:
Employer State:
Employer ZIP Code:
Plan Effective Date:
Number of Eligible Employees:
Number of anticipated HSA enrollees:
Existing HSA Program (rollovers): Yes No
 
Referral Source Code: (optional)
Broker Firm Name: (optional)
Insurance Carrier Name: (optional)
 

Other

Broker Name: (optional)
Phone Number: (optional)
E-mail Address: (optional)
 
Contact Information:
Primary Contact Name:
Primary Contact Role:
Primary Contact Phone Number:
Primary Contact E-mail address:
 
Secondary (Payroll) Contact Name: (optional)
Secondary Contact Role: (optional)
Secondary Contact Phone Number: (optional)
Secondary Contact E-mail address: (optional)
 

Administrative Fees

Note: Employer billed administrative fees available for groups with over 25 anticipated HSA enrollees.
Set Up Fees: Billed Charged
Monthly Maintenance Fees: Billed Charged
 

Notes Section (optional)

Please provide any relevant information the Implementation Team should know.
 
Word Verification: (Type the two words that appear)
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