The URL can be used to link to this page

Home My WebLink AboutContract 2178r ... C.'. ,- .. ~ b ,z d/l. ^. ~-~- ~ i.a - . ~ .~ r ~, w ~ H ~ t. , stim. s.o .t-a {...H~ w _.~. ...a .... 2't7$. Table of Contents Thank you for selecting HSA Bank as your HSA administrator. HSA Bank, one of the leading HSA administrators in the nation, is dedicated to providing the personalized. service you and your employees deserve. Our experience shows that education and communication are important to the success of an HSA program; we have created this guide to provide you with detailed information about HSA Bank's services. As HSA Bank adds services and features for you and your employees, we will send notifications through our monthly employer newsletter. If you have any additional questions, please contact HSA Bank's Business Relations Coordinators by phone at 1-866-357-5232, Monday through Friday, 7 a.m. to 7 p.m., CST or by email at 1 rttrrrc ~.~~€,'ertrz,=rz.~t~'1_~.Er >~~rtlz,c_c=err. To assist you in accessing the information you need to manage your HSA program more quickly, simply click the item within the table of contents to go directly to that section. Group Online Enrollment (GOE) Features Overview ................................................................................. 4 Setup Process ....................................................................................... ..5 GOE Instructions (Employee) ............................................................... 6 GOE Administration Area ................................................................... ..7 Communicating to Employees .............................................................. . 9 Individual Online Enrollment (IOE) IOE Instructions (Employee) ............................................................... 10 Electronic File Enrollment ......................................................................... 11 Paper Enrollment ........................................................................................ 12 Invoicing & Identity Verification ............................................................... 13 llA ~aa~~tril~ui.ir~~~s Basic Contribution Limits &Guidelines .................................................... 14 Comparable Contributions -IRS Guidelines ............................................. 14 Employer Contribution Options ................................................................. 15 Group Online Contributions (GOC) Features Overview ........................................................................ 15 Sign-up Process ............................................................................. 16 GOC Instructions .......................................................................... 16 Optional Dual Control Instructions ...............................................22 Electronic File Upload with ACH/Wire Transfer ................................ 23 Check ................................................................................................... 23 Direct ACH .......................................................................................... 24 Designing Successful HSA Programs Program Design Tips .............................................................................. 25 P1-ogram Design & Communication Worksheet ..................................... 25 Webster Bank Case Study ....................................................................... 26 Training & Education Resources Communication Kit ............................................................................. 27 Presentations ........................................................................................ 27 Informative Website ............................................................................ 28 Online Decision Support Tools ........................................................... 28 T L E C O N T E N T S -2- .. '. e .... . Employee Contribution Options ................................................................29 Account Options Bank Account ...................................................................................... 29 TD Ameritrade Corporate Services Brokerage Account ..................... 29 Mutual Fund Selection Investment Account ....................................... 30 Distributions Qualified Medical Expenses ................................................................31 Distribution Options ............................................................................ 31 Account Access & Maintenance Internet Banking (Employee) .............................................................. 33 ~,'i. _ ~ Employer Site ............................................................................................. 35 Customization Options ...............................................................................36 Reporting .................................................................................................... 37 'ils Business Relations (You) ...........................................................................38 Client Assistance Center (Your Employees) .............................................. 38 Spanish Materials and Support ................................................................... 38 T 0 C O N T E N T S -3- Group Online Enrollment HSA Bank recommends the use of our Group Online Enrollment system for any employer group where the employer is paying any fees due at the time of enrollment, most employees have access to the Internet, and wants to maintain greater control over employees' HSA enrollment and administration. The Group Online Enrollment system is a two-part system - employer setup and employee enrollment. The employer setup allows you to select how your employees enroll, when the applications are processed, and who is paying the fees associated with the HSA. Part 1: Employer SeFOp ~ n HSA 6ank~ ~~ n '. IXemn, Lie~Y cmpbyar YVeG~[e (Gr up ~ ~"~" ~ - ~-rd Y f Enrobv t JP) ` \ / Immedate ~ ~s\ ,I - dme,d ~, t` ~,ra N 3Y APpmval PaR 2: Employee Enrollment Pcrcorel Into mewed Ceslan lmk caned Mcpun! -laclramc ands EmPloYee fm Empbvaes Aut bptbne nrolMcern Cpenz mPaper s IvPe Y16kane Kd Eagn Features Overview HSA Bank's Group Online Enrollment system has many features and options that make enrolling your employees in HSAs faster and more convenient. Multiple Locations, One Solution If you have employees located in multiple locations, HSA Bank's Group Online Enrollment system provides one convenient solution to allow each employee to easily enroll in his/her HSA. Your employees access the link you were given after you completed the Group Online Enrollment Setup form from anywhere they have Internet access. Quick, Easy Setup HSA Bank makes setting up Group Online Enrollment quick and easy. You simply sign up with HSA Bank as an employer, login to the Employer Administration Area, and select Settcp from the Group Online Enrollment navigation menu. Then you complete and submit the short setup form. Business Relations Coordinators are also available to assist with the setup process. Once setup, HSA Bank provides you with the link to give to your employees. Several Processing Methods With HSA Bank's Group Online Enrollment system, you choose the level of control you would like over your employees' HSA enrollment. HSA Bank provides three processing methods, including: Immediate - As your employees complete the online enrollment process, the application is submitted to HSA Bank and the account is set up. You will be required to upload a census data file of employees. By Approval - As your employees complete the online enrollment process, the applications are placed on hold until you approve them for processing at your group online enrollment administration page found in the employee- login site of our website. Batch - As your employees complete the online enrollment process, the applications are held in a group, or batch, until the end of the enrollment period (as designated by you during setup). After your enrollment period has ended, all the applications received from your group are processed and the accounts are opened. You will be required to upload a census data file of employees. Electronic Signatures HSA Bank's Group Online Enrollment system utilizes e-sign, which means that your employees do not have to provide a "wet" signature. Your employees will simply agree to receive all disclosures and account information from HSA Bank in an electronic format. Monthly or Annual Invoicing HSA Bank will invoice you for any fees you opted to pay during setup. You may elect to receive an invoice far these fees on a monthly or annual basis. If you elect the monthly invoice option, HSA Bank will send the invoice by email each month to pay for the past month. However, if you elect the annual invoice option, HSA Bank will send the invoice at the beginning of each year to pay for the upcoming year. -4- Accessing Group Online Enrollment HSA Bank's Group Online Enrollment system is available through our Employer Administration Area, which allows you to view your employee list, access the Group Online Enrollment administration area, make contributions to your employees' HSAs online, upload contribution data, and sign up for employer updates. You may also download HSA Bank's Employer Communication Kit to assist in educating your employees about HSAs, consumerism and HSA Bank's services. Setup Process Step 1: If you have not already done so, complete the Employer Sign-up Form and fax it to (920} 803-4184. The Employer Sign-up Form is available at: l~>:1;`~.`. ,w_~J1~Jai-,~~tls.c°~,~~,/f_~~~~z~~,': i;l~i~4~~;~E~s~i,L,i;~li. Within two business days you will receive a welcome email fi•om HSA Bank that will confirm your setup is complete and contain your login username and password for the Employer Administration Area. Step 2: Login to the Employer Administration Area: lilt'f~,:/,j~;;~vli!'~'.~l~;i%fii~4,~ fstl~F!~'i3? r~r3t%i'.S'~;ltt~~tl~.:t`;?\. --1- - - -- _ . _ -~- --------._--- 1-- Step 3: Select Setup from the Group Online Enrollment navigation menu to access the Group Online Enrollment Setup form. Step 4: Complete the Group Online Em~ollment Setup form. Step 4a: Complete the General Information section. Provide general information about the size of your company as well as when and how long your enrollment period will be. If you are working with an agent andlor health plan you should enter the agent's Agent Identification Number (AIN) and/or the health plan code. Your agent and/or health plan will provide these codes. Step 4h: Complete the Enrollment Configuration section. Immediate & Batch -HSA Bank recommends the use of immediate or batch processing for mid-sized and large companies. These processing methods require an employee census file to be uploaded prior to the enrollment period. When employees enroll, they will be required to enter their social security number. If the number does not match a number you provided in the census file, they will not be able to proceed with enrollment. By Approval -HSA Bank recommends the use of approval processing for small companies. No census file is required. The employer approves each individual employee application after the employee has completed the enrollment information. Step 4c: Complete the Enrollment Options section. Determine the fees that you will be paying for your employees and the fees that the employees will be required to pay. Ste 4d• Complete the Invoicing Information section H.~r ~...., : r yy~/~ aFot ... ,..w» p HSA Bank will invoice you for the fees you have opted to pay for your employees. lvotc>.• DEr rrr,t serart the setaap f'€~c`~ rrrrtil}yurr frrr€'e r•crrrar~etl ~~zxcr irti•eriee>. Step 5: Click the Click Here to Submit Form button. Upon submitting the Group Online Em•oIlment Setup form, HSA Bank creates the custom link for your employees to use when enrolling in their HSA. You will be emailed the custom link and additional instl°uctions. The link and much more are also available through the Group Online Enrollment Administration area. -5- Group Online Enrollment Instructions (Employee} HSA Bank's Group Online Enrollment system is a quick and easy way to open an HSA, from any computer at any time. To complete HSA Bank's Group Online Enrollment application (regardless of the processing method you selected}, each application will include: • Name ~ k~~~ , • Social Security Number • Date of Birth - { • Street Address (ccvrnut he P.O. Ba.r) ,"~~ - ~° °~ ~ ~•^ " • Citizenship Status • Employer Information ' ' ° • lob Title If you intend to upload a census file, you may include this information. Any information you provide will he pre- filled when your employees enroll and facilitate a more efficient emrollment process. If an employee opts to give access to an Authorized Signer, or spouse, he/she will need their: • Name • Social Security Number • Date of Birth • Street Address (c•rn~not he P.U. Bo.r) The step-by-step instructions of each processing method are provided below. Immediate Processing Step 1: You enter your employer's online enrollment page (link provided by your employer}. Step 2: You complete and submit the online enrollment application. If your employer submitted a census file, some information may be pre-filled. Step 3: HSA Bank opens the account upon submission of your online application. Step -1: A welcome kit will be mailed to you. By Approval Processing Step 1: You enter your employer's online enrollment page (link provided by your employer}. Step 2: You complete and submit the online enrolhnent application. If your employer submitted a census fife, some information may be pre-filled. Step 3: HSA Bank opens the account once your employer approves your online application. Step ~: A welcome kit will he mailed to you. Batch Processing Step L You enter your employer's online enrollment page (link provided by your employer). .Step 2: You complete and submit the online enrollment application. If your employer submitted a census File, same information may be pre-filled. Step 3: HSA Banl: opens the account at the end of your employer's pre-designated enrollment period Step ~: A welcome kit will tie mailed to you. To ease enrollment, you may also download instructions for each of the enrollment methods through the Employer Administration Area. Select Training Resources from the Resources navigation menu. You can then download the enrollment instructions for the enrollment method you have selected. -6- `: Group Online Enrollment Administration Area Group Online Enrollment Employer Administration Page Once you log into the Employer Administration Area, select Adrninistrntion from the Group Online Enrollment navigation menu. The Group Online Enrollment Employer Administration page provides a number of details about your Group Online Enrollment setup. In the Current Employer Stats box you will find when your enrollment period is set to start and end, as well as the number of current enrollments that have been processed. Below the Curz-ezzt Er~zployer Stats box you will find the links you will need to administer the enrollment of your employees through HSA Bank's Group Online Enrollment system. fir' Employee Enrallment Link View Employee Status To access the View Employee Status page, click the Viert~ Employee Status link under the Current Employer Stats box. The View Employee Status page allows you to view the employees that have completed their enrollment through HSA Bank's Group Online Enrollment system, when the employee enrolled, and what the status is for each employee. .. i t°~ e . s4 - ` ~ sJeitaniei •,i~a:-. t;,~i~ uH,!i.•,u, a..Fr p , ' g t' ~' f 4 Profile Adminrslmtian Contnbu[ians Resources Gmup Online Enrollment View Employee Status cm Enployrr Son Lase ~+arre Flrsi flame SStI Uate Enrollee SI]tu5 - - ... .... E.[ V++:A-: 1~-n .. 3 .. r <. ... r 1 • -: PEn~I v ~: pr.:31 View Pending Enrollments The View Pending Enrollments page helps you track your employees' progress in the HSA enrollment process. If you upload a census data file (see belo',+~ for izzstructions), the employees in that file will be listed on the View Pending Enrollments page with a Pendizzg status. Also, if an employee begins, but does not complete the enrollment process using the link you provided, the employee will be listed on the View Pending Enrollments page with a Pending status. 6'~IelC Ome I' t'nCeLr!It ~ t i f.M f{orn t(f iJO. ~tf Proftle Administratron Contnbutions Resources Group OnNne Enroflment View Pending Enrollments mu Erp~or=~EUrs apt Name First flame SStf S[aBts ~eJete s - .. ,... C'~!. .l ills •..- •- FClll iiJ 4~_ F.~~~J~~ ~Ln - _it~ir_ v-~ C t ._..- 4; ~I'.5= g 4 If you need to remove an employee from your pending enrollments list, click Delete next to that employee's name. You will then be prompted to confirm that you wish to delete the employee from your pending enrollments flirt. Click OK if you do want to delete the employee, or click Cancel if you do not. -7- Upload Census Data (Required for Immediate and Batch Processing HSA Bank's Group Online Enrollment system allows you to submit a census data file, which can make the enrollment process easier for your employees by pre-filling certain fields for them. The census data file must include, at a minimum, the Social Security Number of your employees. Any additional information provided would increase the number of fields that are pre-filled for your employees (HSA Bank recommends including your .~a employees' first and last name). The census data file must be formatted correctly to be uploaded. HSA Bank provides instructions on how to format the census data file as well as a Microsoft Excel template in the Employer Administration Area. Once the census data file has been created in the correct format, simply click the Browse... button, select the census data file from the location from which you saved it, and click the Click Here to Upload File. If the file is formatted correctly, a message stating the number of records that were imported will appear. If the census data file is formatted incorrectly, a message stating the error that has occurred within the file. Note: The census data file does not open your employees' HSAs. You must sendyour employees the link provided after you setup Group Online Enrolbneut, and your employees must complete the enrollment process through that link. Approve i DcCiiitc Appii~antS If you selected the By Approval processing method, you will need to approve each employee that enrolls through your link using the Approve/Decline Applicants page. HSA Bank will send an email each week you have pending enrollments awaiting approval as a reminder for you to login and approve or decline the application. ,~"- .. ,.. .. ~ 1;:; 3'reNivu ABeun+c rn[nzn Ce,r~leoiru[mnn iirriuurc~a+s C:rw[p Oni+n., t+u+,llmrnt ~PPra~~e~Derl,ne RGFlacarts If you select Approi~e, HSA Bank will open the account. After you approve an employee's enrollment into the HSA, you will receive the message displayed below. .: ,~ _, ~ , ?, ~ ~ /~ .,Y~v, Min~+i..+nn.,n ..,r~i.t~..n~,n, it s.u,~.~a-. ,~r i )v.l.r,.,f n+..irn~,.~t ApPto~:e tYer 6ne nyPlrc ar[5 . $ . If you select Decline, the application is deleted and no HSA is opened for that employee. If you decline an employee's enrollment into the HSA, you will receive the message below. z: .~.~,.„ ~ , tLnldo M}m.m•:SSnrxut G.u.nfi•rrnxn t7usrwrece.s f:rnvp rMGex•Ene.rllmc+nl kpvrove~Detline R(lpeCan:3 Note: You are not asked to confirm your selection of Approve or Decline. Communicating to Employees Communication plays a key role in the success and employee acceptance of any HSA program. Below are some tips from HSA Bank on how to communicate the Group Online Enrollment process to your employees, and continue communicating bevond the enrollment phase. Provide Enrollment Link After you have completed the setup process for HSA Bank's Group Online Enrollment system, you are provided an Employee Link on the Group Online Enrollment Employer Administration page. The link reflects the choices regarding the enrollment period, processing method, and fee responsibilities. The link also ensures that HSA Bank can accurately track the employees that enroll through your link are included as part of your group (for reporting and invoicing purposes). Provide this link to your employees to enroll in the HSA. Enrollment Instructions Along with the enrollment link, you may also consider providing your employees with instructions on how to enroll in their HSA with HSA Bank. HSA Bank has step-by-step Group Online Enrollment Instructions that can assist your employees in completing the online enrollment process. You can download the Group Online Enrollment Instructions, based on the processing method you select, from the Enrollment Convnunications section of the Employer Communication Kit. The Employer Communication Kit is located in the Employer Administration Area by clicking Training Matel-ials from the Resources navigation menu. Communicate beyond Enrollment HSA Bank encourages all employers to maintain a regular ongoing communication strategy regarding HSAs to build greater employee acceptance and enable employees to realize the full benefits of their HSA. HSA Bank can assist you in your ongoing communication through our Employer Communication Kit. Each month a communication with timely, pertinent information is provided to you through our newsletter -Employer Update. These monthly communications are provided in a Microsoft Word format to allow you to customize the message for your employees. Note: I'OU i11aV al.S'O CIOYL'11lOaCl the 0I1g01J1g C0171117![711C'CltlO11S 6'0171 the POSt-e71YOlllllellt CO1i111711111Cat1011S SC'C't1011 Of the EmPloyeY C0/77I1n1111CCltlOn Klt. The El71p10)'el' CO777/7711i71C'atlOn KIP 1S lOCateCl lit the Einj3lOyei" f~C1i171111StratlOil !-~7"C'a l~l' C'llC'liCn~ Tl'al)Ill1g MaterlCll.S fl"OI)t the RC'SOItYCC'S 31a1'Igatl071 F72e311[. -9- Individual Online Enrollment HSA Bank recommends the use of our individual online enrollment system for individuals and tnay be used by small employer groups that are not paying any fees (e.g. setup or check order) during the enrollment process and will not be involved in ongoing contributions. Employees will be required to pay for any applicable fees with a credit card during the enrollment process. If used by employees, there will be no tracking of the employee back to the employer and the employee will be treated as an individual. The individual. online enrollment process has four basic steps. Personallnformation individual HSA Bank's Online ' Account Options Accouni Opens Electronic . -- Enrollment Website - Welcome Kit *~, Esign 1. Employee enters HSA Bank's online enrollment page (https://secure.hsabank.com/enrollment). 2. Employee completes and submits the online enrollment application. 3. HSA Bank sets up the account. 4. The employee receives a welcome kit via email. Individual Online Enrollment Instructions (Employee) HSA Bank's Individual Online Enrollment system is a quick and. easy way to open an HSA, from any computer at any time. The basic steps of our individual online enrollment system are outlined below. Siep is Eater ii,SA Bank`s oazliaie c:nr-oliment page (www.secure. hsahurzk. cnna/enrnllrnea~t). Step 3: Corn/Mete anti suhn~it the oazline eazrallaa~~ent a~'rplication. Siep 3: HSA Baank processes the accntarzt withiaz rn"ae busiaaess duy. The identity of all applicants is then verified. If ~a'e are uraahle to verifv tlae ider~tzh; tiae applicat2t will be notified m2d be usked to provide additional clua-ify°ing docurraents. When the applicmat's ideretith is verified, HSA Barak opei's the aceoaant. Step 4: A welcoane kit arra~ves by ea~Tail. If ordered, checks and debit cards will arrive wh~laiaa 7-10 baasiness dati~s. Basic Enrollment Requirements To complete HSA Bank"s Individual Online Enrollment application, your employees will need to provide their: • Name to -. ~,:, • Social Security Number • Date of Birth • Street Address (cc~anraat be P. C). Bax) 4 . • Citizenship Status _ -z • Employer Information • Job Title '" -' , ` ~~ If your employee has opted to give access to an Authorized Signer, or spouse, he/she will need. their: + Name * Social Security Number • Date of Birth • Street Address (caavic~t be B.O. Bczx~) .; S .a =-> s '~ t-' f'- = { ~,T,_ .ti `_ ,_. ~`~ S ~ _~5 ~' ~ ",: _:. ._.,i _,.5 '~~ ~:~ ,': ~~ ; -: -10- Electronic File Enrollment The electronic file enrollment process allows HSA Bank to open an account based on an electronic file and the employer or third-party demonstrating the employee's intent to open an HSA. Once HSA Bank has received the electronic file and verified each employee's identity, the account will be opened. The electronic file must contain each employee's name, date of birth, address, social security number, citizenship, and employment status. The steps for setting up and enrolling employees using the Electronic File Enrollment method are: Employer Set-up Step 1: Contact Business Relations to initiate the Electronic File Enrollment method. Step 2: The employer creates a sample em•ollment file and provides the file to HSA Bank. Step 3: HSA Bank approves the enrollment file format or provides the employer with changes that must be made to have the enrollment file format approved. Step 4: Once the enrollment file format is approved, HSA Bank provides the employer with the FTP transmission information. Step 5: Enrollment files can be transmitted. Enrollment Step 1: The employer completes the enrollment file information and provides the "intent" to open the HSA. The information that is required for the enrollment file is the employee's name, street address, date of birth, social security number, employer, job title and citizenship status. Step 2: The employer or third-party creates the enrollment file. Sten 3: The enrollment file is unloaded to HSA Bank's FTP server. Step 4: HSA Bank sends an email confirmation to confirm the file has been received. Step S: HSA Bank opens the HSA after the employee's identity is verified. -11- Paper Enrollment You may also choose to have your employees complete and submit a paper application to setup the HSA. HSA Bank recommends that you pre-fill the applications with your Federal Tax Identification Number or provide it to your employees to include on the paper application. This will allow HSA Bank to properly track your group. Paper applications require two to three business days to process after receipt by HSA Bank. Paper Enrollment Instructions (Employee) Step 1: Cotnplete tlae application. Enter t/te Persottul Infonnutir~n that pertains to you, the uccounthalder. Alsa complete the HSA Account Options, Tjpe of htitiul Deposit ctnd Eligibility Requirezrrents SPCItOtt.S. Step 2: Decide if you worald like attyotte else to ha}~e access to your HSA. If you would like to gi~'c another party' access to your HSA, complete the Authari~c~d Signer section. Step 3: Decide if`yvu x~auld like to designate a bette~ciary. If'you would like to designate a beneficiary, complete th.e Designczticut of Benefirinrv section. Step -l: Sigtt the application. Paper upplicution.s must also hate your .signature. If'you hcn~e opted to include an Atrthori~ed Signer, that person must also sign the application. Any applications that are not completely filled out will be returned. Once HSA Bank has received the completed application, the account will open in ? - 3 business days. Within 7 - 10 business days you can expect to receive your account welcome kit. Other materials will be sent separately as requested. -12- Invoicing HSA fees can either be directly debited from your employees' HSAs or HSA Bank can invoice you. You have the option of prepaying fees, or being invoiced on a monthly basis. HSA Bank charges a monthly account maintenance fee. To discuss customized fee options, contact HSA Bank's Business Relations Coordinators. HSA Bank's invoicing department tracks all fees paid by employers. If you choose to receive invoices for fees, please remit payment only after receiving the invoice. If an employee terminates high deductible health plan coverage or employment with your company, please notify HSA Bank promptly to avoid being invoiced for that employee. If HSA Bank receives notification prior to the 25`h of the month, we will not invoice you for that employee beginning with the invoice for that month. All invoiced amounts must be paid in full; please do not make adjustments to the invoiced amounts. You can notify HSA Bank by removing the employee on HSA Bank's Employer Administration Area or by completing our Employee Adcl/Re~noi~e Form located at I;;Fa?:;~1~~ ~x. t~~ .f~=,~li~~~3~~~. ~.<.x~nlt~.!€~sr~~1~~r1=~1~~~~°~° _ ~~~lcl.~`. For questions about fees or invoicing, contact HSA Bank's Business Relations Coordinators. Identity Verification HSA Bank, in compliance with the USA PATRIOT Act, is required to obtain, verify and record information that identifies each person or entity that wishes to open an account. The USA PATRIOT Act helps the government fight the funding of terrorism and money laundering activities. Therefore, when your employees enroll in an HSA, HSA Bank requests their name, street address, date of birth, social security number, citizenship status, and employment details. The employees' information is processed through an automated system, which verifies the identity of your employee. In the case that the automated system is unable to verify the identity of an employee, HSA Bank will attempt to collect additional forms of identification from you. Acceptable forms of identification. -13- Basic Contribution Limits and Guidelines The IRS determines the maximum amount that can be contributed to the HSA in a calendar year. For 2008, the maximum contribution. limit for individual plans is $2,900 and $5,800 for family plans. The 2009 limits are $3,000 for individual and $5,950 for family coverage. The IRS reviews these limits on an annual basis and adjusts them as needed. Employees do not need to prorate their contributions so long as they have high deductible health plan coverage on December 1" of the year coverage began and they maintain that coverage until December 31~` of the following year (see table below). Employees that change mid-year from single or family coverage to the other will need to prorate based on the IRS determined contribution limits for that level of coverage. If contributions are not prorated and qualifying HDHP coverage ends prior to completion of the required period, excess contributions are subject to income tax and a tax penalty. Covera a Be ins Covera a Ends Allowed Contribution 2007 Allowed Contribution 2008 1/1/2007 12/31/2007 2007 IRS maximum $0 7/1/2007 12/31/2008 2007 IRS maximum 2008 IRS maximum 7/]/2007 4/1/2008 6/12 of 2007 IRS maximum 3/12 of 2008 IRS maximum 1 1!1/2007 11./1./2008 2/12 of 2007 IRS maximum 10/12 of 2008 IRS maximum All contributions, regardless of their source (you, your employee, and IRA rollovers) count toward the contribution limit. Since you and your employees can make contributions to the HSA, it is important to coordinate cortributiors tG a'void excess CvntriblitionS and tax pcnaltIes. As of January 1, 2007, you have the option to roll HRA or FSA funds into your employees' HSAs on a one-time- only basis, which provides your employees with funds for medical expenses from day one. If your FSA plan allows FSA extensions, your employees can contribute to the HSA if the FSA balance is zero on January ly` or if the FSA balance was rolled over to an HSA prior to January 1". Consult your tax advisor or the IRS for details and reporting requirements in regard to taxation, fund rollovers and other stipulations. The IRS allows individuals that are age SS or older, and not enrolled in Medicare, to make catch-up contributions to their HSAs. Comparable Contributions -IRS Guidelines According to the IRS, your contributions to employee HSAs must be comparable between all eligible employees. The comparability testing period is based on a calendar year and determined on a monthly basis. Contributions are comparable if they are either: 1. The same amount, or 2. The same percentage of the annual contribution limit. Example: Health plan /Employee Status This tahle displays a sun~ple of con~Apa~rable cortrribtctinns, based on the compnrc~bility rules in effect as of Jm:uary 1, 2007, in one scenario with full-dine and part-tune entpk~yees. Family Full Time: Single Self Plus One Self Plus Two Self Plus Three HCE Non-HCE HCE Non-HCE HCE Non-HCE HCE Non-HCE Same Dollar $100 $150 $l00 $1.50 $100 $150 $1.00 $150 Escalating Dollar $50 $75 $ 100 $150 $300 $400 $500 $600 % of Limit 50% 60% 30% 40% 60% 70% 90% 100% Part Time: Single Self Plus One Self Plus Two Self Plus Three HCE Non-HCE HCE Nan-HCE HCE Non-HCE HCE Non-HCE Sarne Dollar $50 $75 $50 $75 $50 $75 $50 $75 Escalating Dollar $50 $75 $50 $75 $150 $200 $Z50 $300 % of Limit 25°Io 30% 15%n 20% 30% 35% 45% 50% -14- The single and family categories are tested for comparability separately. The family categories of self plus one, self plus two and self plus three or more are tested separately. However, if you contribute to these categories, you may not contribute less to the self plus three or more category than is being contributed to the self plus two category, and the self plus two category may not be less than the self plus one category. As of January 1, 2007, the IRS allows an employer to make additional contributions to non-highly compensated employees' (Non-HCE) (defined under Code § 414(q)) HSAs as an exception to the comparability rules. However, the additional contributions must be comparable to all lower-paid employees. The comparability rules do not apply to your contributions made through a Section 125 cafeteria plan. You may make matching contributions through a Section 125 cafeteria plan (non-discrimination rules apply). Employer Contribution Options You can make contributions to your employee HSAs through the following options ~ ~~~~~t.g1> t ~3~ai~~~ C a>r~t.- °~' ;__, l',[~_ t~s~~~~L. ~,i~~_~_~13!~~ 1s:5_, °~C°" t, or _ ' ' . When selecting your contribution option you should consider the size of your group, frequency of contributions, and lead time needed. Group Online Contribution You can use our Group Online Contribution tool to send contributions via the Internet. Once you have signed up, you can log into HSA Bank's Employer Site and submit one-time or recurring employee pre-tax, employee after- tax, and employer contributions at the same time. • Employee pre-tax -For employers with a Section 125 cafeteria plan, employee HSA contributions can be ;nacle nn a pre-Yssx hacig, • Employee after-tax -Employee HSA contributions can be made on an after-tax basis. Employer -You may make HSA contributions to your employees' HSAs. To sign up for group online contributions, complete the Group Online Contribution Form and ACH Agreement at (i~i.tls '~~.~-~,~-~ l~__ti~, ~€i'F,_~e 3~~~i~c>€~t~,~w`-E ~3~.~~ u~~ii~3.~° ~.t~r,i:~ih=~~~r~t~s_l;>c~t). If you have not previously signed up for the Employer Site, please contact a Business Relations Coordinator for assistance. Fe~tuCeS OVer\/1eW HSA Bank's Group Online Contributions system has many features that make using the system and contributing to your employees' HSAs faster and more convenient. Automatic Fill-Down HSA Bank's convenient fill down feature allows you to enter a contribution amount one time and fill in that contribution amount for all employees. Confirmation Notices HSA Bank sends you a confirmation once the transfer has taken place. For recurring contributions, HSA Bank will send a confirmation each time the contribution is made. Contribution Templates You can use a completed contribution from the Contribution History section as a template to create a new contribution. All the information from the archived contribution is included in the new contribution. Simply select a new start date and make any other necessary changes. Optional Dual Control HSA Bank allows you to select a dual control option to verify the initial user set-up to the correct accounts with the correct amounts. Dual control requires one user to set-up the contribution, and a second user to review, verify and approve the contribution. The instructions far dual control are available on page 3 of this instruction booklet. Request Contribution limit Change HSA Bank limits the amount you can contribute to ea,,~,,,,~,,,,,,,,„, your employees' HSAs on a given day. You may ~~G~~ ,,,r _ ~, „ ,,:,,<< 7,_ , ~~E,, , ..~, ~ ,,,, , ~~._..: , request that HSA Bank review your contribution ,_ limit by completing the Group Online '~' ~"'~~ Contribution Maintenance Farm. Once the form is -15- completed and signed, fax it to HSA Bank's Business Relations at (920) 803-4184 or mail it to HSA Bank, P.O. Box 939, Sheboygan, WI 53082. The form is available for download under the Banking Information heading on the Group Online Contributions main page. Change Banking Information You can change your banking information by completing HSA Bank's Group Online Contribution Maintenance Form. Once the form is completed and signed, fax it to HSA Bank's Business Relations at (920) 803-4184 or mail it to HSA Bank, P.O. Box 939, Sheboygan, WI 53082. The form is available for download under the Banking Infonnan~on heading on the Group Online Contributions main page. Accessing Group Online Contributions HSA Bank's Group Online Contributions system is available through our Employer Administration Area, which you were given access to when you signed up with HSA Bank. Sign-up Process During the five-step process of setting up your company with HSA Bank, you also may have completed HSA Bank's Group Online Contribution Form and ACH Origination Agreement. If you have not completed the forms, you may download them at http./,r:~~~~~~;~-.l~~aC><s~~~.~:.~sz~ll~4~rrs~st~.~~,~st~r~ ~:z~~lir~~° ~°~~~e~cz~i3~~.~t~~~>t~~;_i:cit and fax the completed forms to Business Relations at (920) 803-4184. Once the Group Online Contribution Form and ACH Origination Agreement are received, HSA Bank will contact you when contributions can be initiated. Accessing Group Online Contributions Once you log into the Employer Administration Area, select Online Contributions from the Contributions navigation menu. Once you have accessed Group Online Contributions, you can view pending contribuiious, add a new contribution, view your contribution history, and verify your bank information. Group Online Contributions Instructions Add a New Contribution After logging into the Employer Administration Area and navigating to HSA Bank's Group Online Contributions main page, follow the steps below to add a new contribution. Step 1: Click on the Add New Contribution button Step 2: Name the contribution Step 3: Select the frequency of the contribution (one-time and recurring options available}. The frequency options are listed below: Once - A one-time contribution is made on the date selected by you Weekly - A recurring contribution is made each week on the day of the week selected by you Every other week - A recurring contribution is made every ] 4 days (or the next business day) of the initial date selected by you Twice amonth - A recurring contribution is made on the 15`~ of the month (or the next business day} and 15 days from when that contribution posts End of month - A recurring contribution is made on the last business day of each month Monthly - A recurring conh•ibution is made each month on the dale (or the next business day) selected by you Quarterly - A recurring contribution is made every 90 days (or the next business day} Yearly - A recurring contribution is made each year on the date (or the next business dayj selected by you Daily - A recurring contribution is made each business day Step 4: Enter a start and end date for the contribution -16- ~..- „F= Step 5: Input the amount to be contributed to each employee's HSA. HSA Bank's Group Online Contributions system allows you to classify your contributions as Employee (used for after-tax dollars}, Employee Pre-tax and/or Employer. The purple arrow next to these three column headers is the automatic fill-down feature noted on page 12. ~ ~ a ~~, ~ VJeicome CcJrtar:t tJS I CE'Cd *iere to iceiotf i~A Pmfife Administrsfinn Contributions Resources Add Cantriqution Flees= i;LtnplEtE the Intelmaticn help;.; t0 scneuule roar coniriCUtian. =JI transfers begili processin7 as of 2:OU p m C'ST cn@ burin=_ss da. hefafE ih@ IransfEi IS SiYiedUled tai p0e[ 10 the Elrlple: EE5 3000UI1t5. Ong titE Sron_t@I' has bESUn GIYIfE551nj:.: UU {e;;ll nut h@ 361@ lG ? dit 0l +:anCBl the frarister. 1 Enter Cortnntrtion name-Tne ~ar:tr-;.+UGer, 'arTC is usatl tp hElp ;cu idzn*fi a sperjtiC transfer- YOU Ina; 4Jar:tio InduCE the date antl~cr frequEnc~ tc Help Itlentif; the Transfer 521001 FreQUEnCV: 'Y 7:J can uuEtEnttlliE If :pU naltf a ^_nE-tllltE or rBGlrrin:J ndnsiE( . Select Statt Elate and End Date. Thz statl datz Is th=_ hrst •7ate rpu v:ou!d me funds to postto :~nu aniGlo~22s accnwtts. :=:hll=the zntl data Is the last tlatz ,ou :avant fwids to pose if , ou do ooK~ei2ct are znd date thz Uarlsfzn~nli contlnua unnl , ml zdrt or :an%21 the ll'anst2r Enter ConMbtnion kmoun[s"'i ou arE pr~?itletl r:iih ihruc r_r.lumps t;rentrii;uticn5-Entpiv;ga ruse:'tct afrer-ta •. doll2r5' EI»GI•^~ce'rr5~ [ar and Emplcy er ff ine same anscunt applies to all empia;eE5 use tn2 till dc::un fEature* Onte 'vu bare cOmpt21©•~ alt lE,uire±i Intvl»tallal'1_ plEas2 clliA ';ay2 to contimx the nanstEl -subLtal sf @acti conVlbuM1Or: tip:2 al':tl 0':51311 total :k11i b2 715GI3:etl Jn the nE.t G3g2. Fn9r Year ':.aninbunan rlalne Frequent, ~rt Gate EndC >Elsrt -rre_ N 5'elec _ Ciear y IrAZiantE ~ -at C'r" FlJ>f :: donne - - •.. 50."vl7 aClau Sr':5U Cme. !aoe w'i SU.~iJ 5r.1 110 Ei.:.00 Step 6: Review the contribution. If the contribution is correct, click on the checkbox under the heading ACH Authorization and then click the Co~zfirr~z button. If additional edits are required, click the Edit button and make the necessary edits. If you no longer wish to submit the contribution, click the Cancel button. >~~~ ~ ~ ~ r ~ Pra61e Administretiort Contributions Resources Onllne Contribution Confirmation FleasS :_rt, thatihe Ilitannatlan Ils{4C tteir,w is cair47.anC print this cape tar ~u reccrJa. It all Infcnnatl 4r. 15 correct clteU Vie 4~.Y aulherl:af on Co~.an:. ;1'. attne Gutt~n ,.t'a'e ka.e t-u....U:a llt'.6 t. mave .ta tnE-f~ln. Ie...Cic ~.r.~rc lancer nosh=srCmft, jai c. ,:ii:4 _a... c. antl n„+,tn return L: tl':E I~:a.n cpntnaunon pG9. ~I"-i6t=r, 2.'.•p'J~.BSS~n f"''.J.m Ti~rc'pus.255:"'L+Ia~e Ne:"n.,f~r.. ::A'~2CUleJ t' Ii lihe 5m '. e~a...~~IS Jncc tt: h'3nst2r has begun [:r;~:'ESST: i{~,,,,inntna _f.AelO etl:l 7t .;6n~El~-3 tlan3fer. rn...~ -, ». ~ ': .~~.: slcr C:fir..... rn~ f i I .... t; Se~it...L~t ~an~e~ -17- I ,- :~ Edit a Scheduled Contribution Once you have scheduled a contribution using HSA Bank's Group Online Contribution system, you can still make edits until 2:00 p.m., CT, on the business day prior to the contribution start date. Below are step-by-step instructions on how to edit a scheduled contribution. Step L• Locate the contribution to edit in the Pending Contribution table. Step 2: Click on the Edit link. Step 3: Make the necessary edits and click Next. Step 4: Review the contribution to ensure all edits have been made. Step 5: If the contribution is correct, click the Con~rrn button. If additional edits are required, click the CarTCel button and make all necessary edits. -18- F Cancel a Scheduled Contribution Once you have scheduled a contribution using HSA Bank's Group Online Contribution system, you can cancel the scheduled contribution until 2:00 p.m., CT, on the business day prior to the contribution start date. Below are the steps required to cancel a scheduled. contribution. Step 1: Locate the contribution to cancel in the Pending Contribution table. Step 2; Click on the Cancel link. Step 3: Confirm that rl ~~ ~:ontribution selected is the contribution to cancel and click Cancel Transfer. - - -~. `>., ~3 ~,,,~~~me~ _ ,.,; <N~,tl Profile Adminislrafwn ContriMrtions Resrnfrc~ Cancel Pending Convi6ution r, a, Cn „ T;,;anccl tie pendnp banst=r. please se~e~.t -a~ i'f~'~5~':.`k• Gel~~.~~ 4]nCH ifaf19f6r Rk;:J. r, {e. f:;:ir: 1'rsi+et=r: -o4e ~~ Note: Once a scheduled corztribzttion is cancelled, it can be viewed in the Contribution History table. -19- >t.y ~~~ r _ t:=s ~~~ ~:~_. '~ ~;° i~.. Add an Employee HSA Bank makes adding employees to and removing employees from the Group Online Contribution system seamless through our employer site. Step 1: :ion navigation menu. Select the Employee Adrnirzistrtztion link from the Administrai ~< ,~,, ~_ ,~~' t=,~.r,~ , , v..~~...~~F err ;~~~,~,~,~ Step 2: Click on the Add Etz7ployee button at the bottom of your employee list. ~° z .- ~~ ;. ,,Eleen,e. ~ ,.: ~ „ / . Profile Administr®twn Contributions Resources Employee Administration let ~. ,x•.4'1.'. ee:tt.E .he.l i. 1.'e lcP, .. ihEi ry it tltE r Y.,:., th=1: t.. .,'fl_y2t-II 51~,. a:. .. ulv.?~. I 1 a _.,.utta :"I ,EECI ..t. .le_ltl_ e.~d_. a~.~ =n. ,ial 6eviiiif. i.~i.i.., i. SZ(.Ar,;ta fi;95 ;I :iil -- :i. :ubi N :.. to.'.II~.:Ei ,i 1. ...~::L~'_ ti'.-1: 7' -3s ~., _....:. 1. E-. ,~ p,.,. 11 :(err- ~u. 4Ei arJ c. .. I: r•a ~I:. _n c-: e= ci>n_~ .:nla .n t...-.;. ..~._ .'r> ...:;.:; ~. .r..;r.',z tt: ra:..,<. - _-. --- d_:_~ ,IEas-.~ .area ..,. ' It.~;t t = ic: ...aaE t~,.l, a„n uo. ._<~. ..v. ,._~.. b'ci~. -_. -=s rr.' t .nl n;;v e. :., ~'r-1. .: e ~:air - ..-~.; an '. , '.,E i. -.n:. -,t.rn~:a. r.., a, : . .,...,,-.. ~ - c...;.:. .~ .. ARtl 6npb; Remo•:a Entpioye'e _.. ~; Step 3: Enter the employee's last name and Social Security Number. Step 4: Click on Add Employee. _.'" ~, +.~ k _...;~6. 1~EIea ~. ._I ! 1_~ _ Prnrue Administration Contributions Resources Add Employee Gi-..i 5. it•. ~cf tl r- -. .._-~J .li .i t.. 7.. .~!'1 'Snl ".cE :I]Iliat:; ... ~,cca: i i. a:'.:i=^: 'H?-iE '7 a:.tl c.4.- E-~_t`,C'!'c_.I .., .,.u a. ..,t,..r.. n, t:4b_ _~,_ I._ ,.^. xti-^ Ua.: iu .~. .~. ir_:i%li., .3.3..1:. .'~'U , ~: Acic EniG:aYee Cancel _ Note: Once yoze have added an employee to your employee list, the employee is also added to arzy sefzedzzled contrbutions with a dollar amount of $0.00. You must edit any scheduled contributions to make the appropriate contribution to the newly added employee. -20- h. , Remove an Employee Step l: Select the Employee Adriainistration link from the Administration navigation menu. ~ r- z ~:~ . r :a:: ¢; ~: t~/ Step 2: Check the box in front of the employee(s) to remove from your employee list. Step 3: Click on the Remove Employee button at the bottom of your employee list. ~` ...6 , ~ ~` ¢q}~ l'INFO P Ec,: J:.1 i.. -:C'=E'~t;c't ~~ ^ i Profile Administration Contributions Resources Employee Administration - 'lll_t: eE~HI_ ..i:'. - a. E~EJ _.<. a alb .1`e. f, t~fi i. tt :'tlte Ge~R "u 5 v - I..I. ~.::~ I,.t! ~„-~:il. ~e.5 1 I _a..a .t„ii.._-..1 i .,.. . i.:Mil ~.~'. 1~, ..,t (_YEc_.EI.. _.. 3t.3 a.:... zlal s.. ino L.,n:,._ .I, ~ 5el:ar.e ua~< If :~~n _.ll sure ,T .. au,l:at ~tY_~Me~_u I.. - :. ir~~:r:L.~.=s+"I .teL;~ Est 3n: u,~.ll 31:~uh1'IS 3.11 .1 V:.e t t, t.ll ii. .)nl3 0 _e'tt~,a :'..a:l'.'r -.I'~p lkt .'~i'1,',r ~:f -r= -.. .-n .. r, .,I,F.3r HS rf. il~_. ,Ib ~ .a_.~„i„-I,=.,r. 1 - `~e. uss~ ,_31 ~..,::. ..._ .~s~~ss ~: nut~:r= v. wuclz enc ~u ~' :.5' ,iht t.~ _tlf..: ,_~.t. ir.l>L' ....:,:.~~ .~. r:.::..'. i..__'.:r. :. ,..._:. 7,t3. tel.. u~t'ta:~t. _..3e. __b., be 2: d ... t.. :itlJ Emu{oy ae Rerio~:e EmWu; ee Step 4: Verify the employee to remove and click on Remove Employee. .3 f Praflle Admlrnstrotion Contrab-utions Resources Remove Employee »r,a = anGl. c :.:.~r~ ~ .l ~r;~~3r.. .I _:fuizd nt ii't ~ nplr,t_q ISt H~ P t_F l~, ~r!ri~ III 5 c I ~TM.br, ~ - - .C r'x-n 31_.ll .~t..... rt,r.n s t3_ _me~ i.. i i Ite..cl1 ~i ,.zls a I.t Yiut 353 wY.GkTe .1 ,., _„ ...... 1 1, _ ... 1. .. __ il.l. Rem> eenm yea ranch Note: Removing an employee froze your employee list will remove the employee from all pending or sclzedzzled transfers. All accouzzt ties will be removed and the employee will be contacted regardizzg any chazzges to the accozznt. If you would like to rerzaove the employee ozzly from a perzdirzg or scheduled transfer, use the Edit a Scheduled Contribution feature azzd set the employee's dollar value to $0.00, -21- z3: - ~, ; _; `. ,{ F' ;: Optional Dua( Control Instructions HSA Bank's Group Online Contribution system offers an optional dual control feature. The dual control feature requires two users to schedule a contribution, one user to create the new contribution and another to review, verify and approve the contribution. Below are step-by-step instructions for each user when the dual control feature is selected. Add a New Contribution (Initial User} Step l: Click on the Add New Contribution button Step 2: Name the contribution Step 3: Select the frequency of the contribution (onetime and recurring options available) Once - A one-time contribution is made on the date selected by you Weekly - A recurring contribution is made each week on the day of the week selected by you Every other week - A recurring contribution is made every 14 days (or the next business day) of the initial date selected by you Twice a month - A recurring contribution is made on the 15`x' of the month (or the next business day) and 15 days from when that contribution posts End of month - A recurring contribution is made on the last business day of each month Mozzthly - A recurring contribution is made each month on the date (or the next business day) selected by you Quarterly - A recurring contribution is made every 90 days (or the next business day) Yearly - A recurring contribution is made each year on the date (or the next business day) selected by you Daily - A recurring contribution is made each business day Step 4: Enter a start and end date for the contribution Step /: Input the a.:tount tv be Vvntrlb'l.~ted tv ea%h employee's H.~iA. Step 6: Review the contribution. If the contribution is correct, click on the checkbox under the heading ACH Authorization and then click the Confirm button. If additional edits are required, click the Edit button and make the necessary edits. If you no longer wish to submit the contribution, click the Cancel button. Step 7: Upon submission of the contribution, an email is sent to all administrative users with contribution permissions. Note: HSA Bank's Group Online Contribution system allows you to classify your contributions as Employee (used for after-tax dollars), Employee Pre-tax and/or Employer. Approve/Reject a Scheduled Contribution (Second User) Step 1: Locate the contribution to review in the Pending Contribution table. Step 2: Click on the Approve link next to the pending transfer. Step 3: Review the contribution amounts and recipients. Step 4: Click on the Approi~e or Reject button. Note: You cannot make edits to the contribution if you click on the Reject button. For mirror edits, do not reject or approve the contribution. Contact the Initial User to make the edits to the contribution and then repeat the Approve/Reject process. If the contribution is approved, the status changes from Pending Approval to Scheduled and remains in the Pending Contribution table until the transfer takes place. If the contribution is rejected, the status changes from Pending Approval to Rejected and moves to the Contribution History table. If the contribution is not approved by 2:00 p.m., CST, one business day prior to the scheduled posting date, the contribution status will change to Expired and will not be processed. -22- E_ ~ - Electronic File Upload with Wire/ACH Transfer The Electronic File Upload with Wire/ACH Transfer contribution option enables you to make contributions to your employees' HSAs. Wires or ACH transactions are sent to a clearing account with HSA Bank. Wires and ACH transactions must be accompanied by apre-approved electronic contribution file, which directs HSA Bank on how to allocate the funds between employees. Note: If the~le has arty errors, an error message will appear irz red. The file does fzot azpload if an error occurs. Getting Started Step I: Contact a Business Relations Coordinator at (866) 357-5232 to setup a clearing account. Step 2: The file can be submitted through HSA Bank's FTP server or Erzzployer Adnzinistratiozz Area. If you are using the FTP server, HSA Bank will provide you with the appropriate information. If you are uploading the file using the Employer Administration Area, login to the site. Click on the Electronic File Transmission tab from the Contributions menu. Step 3: Upload an electronic contribution test file. HSA Bank will then process the test file to ensure a clearing account exists for you and the file format is accepted. Step 4: Once the electronic contribution test file is approved, HSA Bank will email you with permission to begin uploading electronic contribution files. Making Contributions Once you have permission to upload electronic contribution files, you can begin contributing to your employees' HSAs. To make a contribution, upload the electronic contribution file and send a correlating wire or ACH to HSA Bank. HSA Bank will then distribute the funds to the individual HSAs as directed by the contribution file. Check You can make a contribution by sending a check accompanied by the Employer Contribution Form, which should list the name, account number or Social Security Number, and amount being contributed for each employee with an HSA. Contributions made by your employees through a payroll deduction or a Section 125 plan may also be listed on this form. Contributions made by check will generally take longer to post to your employee accounts than the other contribution options. The Employer Contribution Form is available at €~'~:_l?/!u ~ ~~,_(a4 ~l~ ~n!~ ~ ~,s~ir°f~~r ~~~f=~€~~1~[~~a ~n.s aQ~~~t_~;>1 ~~t =_; -23- ACH Direct You can utilize your current payroll provider to make contributions directly to your employees' accounts. Our ACH instructions outline how to properly code each contribution entry. ~,~ ~~;~,<. =~ r j: ACH Process Instructions Through HSA Bank's Direct ACH option, you are able to utilize your current payroll service or vendor to make contributions to your employee's health savings accounts. As an added benefit, HSA Bank has developed a tracking mechanism to distinguish between employer, employee pre-tax through a cafeteria plan, and employee after-tax contributions. ACH Format Requirements as defined by NACHA (National Automated Clearing House Association) Taken front tlae WACHA (Wisconsin Autornctteci Clearing Houre Association) Operating Rules, Appendix trovo. Subsection 2.1.16. Field 1 2 3 4 5 6 Data Element Record Type Transaction Receiving DFI DF1 Account Check Digit Amount Name Code Code Identification Number Field Inclusion M M M M R M Re uirement Contents `6' Numeric TTTTAAAA Numeric Al hauumeric $$$$$$$$¢¢ Len th 1 2 8 1 17 10 Position 01-01 02-03 04-11 12-12 13-29 30-39 Field 7 S 9 10 11 Data Element Individual Individual Discretionary Addenda Record Name ID Number Name Data Indicator Trace Number Field Inclusion O R O M M Re uirement Cuntent s AI hanumeric Al hanumeric Al hanumeric Numeric Numeric __ _ Length IS 22 Z 1 ]5 Position 40-54 55-76 77-78 79-79 80-94 What does HSA Bank Need? Field 1, 4, 7, 10, & 11 Complete fields 1, 4, 7, 10, & 11 as required for file processing. Field 2: Transaction code The transaction code should be set to SAVINGS CREDIT. Field 3: Receiving DFI Identification HSA Bank's DFI or routing number is 075907947 Field 5: DFI Account Number The DFI Account Number is the individual's health savings account number. The account number can be obtained from the employees directly or you can make arrangements with HSA Bank to obtain the account numbers in coordination with your group's enrollment. Field 6: Amount The amount should only include the amount of the contribution from the specific source. If contributions are being made by both the employee and employer, you will need to include two separate entries with the specified amount for each. Field 8: Individual Name The individual name is the name of the employee/accountholder. Field 9: Discretionary Data This field is in the Entry Detail Record and allows financial institutions to include codes, of significance only to them, to enable specialized handling of the entry. There will be no standardized interpretation for the value of this field. Cade for Field 9 Code for Field 9 Type (Current Year (Prior Year Contribution Contribution Em to er ER PR Employee Pre-tax EX PX (throu h Cafeteria Plan Em to ee After-tax EE PE The discretionary data field is used by HSA Bank to determine the type of contribution being made. The table to the right provides a List of codes for field 9 based on the type of contribution and year of contribution. aR . :;,. ~I~ ~m ~ ,%E~:. ~~~ i ~'~ ~~ ~~, x i , ~ka.H f 3 ~, ~ ~;~., a~ Y -- ~#'k ' ;> _, ~a =.i ka» ~.a -24- ~~ s Health savings accounts (HSAs) provide your employees with many great benefits, such as tax savings, additional retirement savings and control of their healthcare. HSAs benefit you as well by reducing your health plan premium expenses and payroll taxes through contributions to your employees' HSAs. However, the benefits HSAs offer you and your employees will most likely go unrealized unless your HSA program is designed to encourage participation. Program Design Tips Below are several tips that can help you design a successful HSA program: Consumer Directed Health Plan (CDHP} &HSA According to an April 2006 article in HR Solutions Today, annual premium costs of CDHPs average 33% less than non-CDHP. Incentives for selecting a CDHP and determining how much of your premium savings to put back into your HSA program are key to its successful design. • Offer to pay a higher percentage of the premium on the CDHP • Ease financial concerns by providing two CDHP deductible levels • Pay tl2e initial set-up and monthly fees of the HSA • Contribute to your employees' HSAs Education & Communication HSAs are relatively new, so education is extremely important. In a survey of HSA Bank's employer relationships, employers that spent more than one hour educating their employees about HSAs experienced 19.2% greater acceptance. • Educate your emplayees and their spouse (when applicable) • Utilize HSA Bank's Employer Communications Program, which provides: o Timely and relevant communications to distribute to employees o Webcasts and Adobe a Flash presentations available for download Program Design Examples Premium Concerns Addresses employees that place a high value on having low premium costs. • Pay 80-100% of employee premiums towards an CDHP • Offer several deductible options to ease the transition to HSA plans (Ex: $1,200 & $2,500 individual deductible levels) Deductible Concerns Addresses employees that are concerned about high deductibles. • Contribute 50-100% of the CDHP deductible to the HSA • Pay the applicable set-up and monthly fees associated with the HSA Combination Addresses employees that place a high value on having low premium costs. • Pay 75-100% of employee premiums towards an CDHP • Contribute 30-60% of the CDHP deductible to the HSA • Pay applicable set-up & monthly fees for the HSA Program Design and Communication Worksheet HSA Bank developed a worksheet that can assist you in designing your HSA program and communication strategy. Specific recommendations regarding program design and tips for communicating the HSA offering are created from your answers to a series of questions. The questions cover topics such as the number of people your company employs, other nan-HSA compatible plans you are offering far the benefits period, yaur objectives for offering the HSA plan, your premium costs and the amount you plan to contribute to your employees' HSAs. The worksheet is available at ~:/!~•- e,- ~, .tr.4 .[~ €:f.~:~~3,. ~ ~?;~. -25- Webster Bank Case Study HSA Bank's dedication to account-based health care since 1997 and working with thousands of employer relationships developed an understanding for designing successful health savings account (HSA) programs for small business, mid-sized companies and large corporations. Below is an example of HSA Bank's experience and expertise helping a company design a highly successful HSA program. HSA Program Design Features Incentives Promote and link health and wellness program. In 2007, Webster contributed $150 for completing an initial health assessment survey and $350 for completing the fitness incentive program. Preventive health services (physicals, immunizations and vaccinations, mammography, OB/GYN exams, and colonoscopies) have first dollar coverage. Communication • Overcoming misconceptions about high deductible health plans (HDHPs) by employees (and as importantly, their spouses) was a major communications challenge. • An extensive communication campaign was conducted in the months leading up to open enrollment for 2005, and each year thereafter. • Employee meetings & webcasts • Home mailings (to reach the spouse) provided examples of how employees can save money and "worst case cost scenarios" in the event of catastrophic medical expenses • Online access to health & wellness information, claims & cost data, benefit plan information, WebMD, fitness incentive program. • After the fu-st year, testimonials by employees enrolled in HDHPs helped dispel many concerns about these plans. Results HSA Bank's recommended plan design lowered employee costs and exposure, even for employees that had high medical expenses. • The maximum employee cost exposure (employee's premium, deductible amount, coinsurance and company HSA contributions, was reduced 28.6 percent for single coverage and 37.5 percent for family coverage when selecting the HDHP over the traditional plan. Ina 2004-2007 Retrospective Experience Review by Aquarius Capital, Webster Bank had several positive results from offering an HDHP/HSA, including: • Cost increased about 1 % per year compared. to a norm of 9%-10% for like benefits. • Overall cost per employee (net medical expenses plus HSA contributions) decreased an average of 1.1% per year. • Net expenses per employee for the HDHP/HSA with an employer contribution was nearly 18 percent less than the traditional plan in 2007 (illustrated below). Traditional Plan $455.30 $462.12 $484.76 $479."23 HDHP/HSA Plan ___ $339.02 $374.87 $291.35 (widaot+t nn e~rt?lwcr ccuitriba~tion) HDHP/HSA Plan ___ $378.85 $416.77 $394.80 f ovitFa Sri era~iulover c~oi~trih~ttiori 1 HSA Bank's Business Relations Coordinators can help you design your HSA program to maximize your savings and the benefits an HSA can provide your employees. For more details on the services HSA Bank's Business Relations Coordinators can provide for your company, please see page 39, -26- Employer Communication Kit Increase your high deductible health plan enrollment by 20% by integrating with HSA Bank. Adding a health savings account option to your benefit plans can save your company money without losing health coverage. A key to a successful HSA program is educating employees. A recent survey of HSA Bank's employer relationships indicated that spending 90 minutes educating employees about HSAs produced a 21.2% higher enrollment rate. This could save you an average of $30 a month for individual coverage and $73 a month for family coverage versus a traditional plan (ehealthinsurance.com}. HSA Bank's comprehensive communication kit guides you through the implementation, pre-enrollment education, enrollment instructions, and ongoing communication for your HSA program. The kit combines presentations, printed materials, calculation tools and employer-facilitated memos. The Employer Communication Kit is available for download from HSA Bank's Employer Site and contains the following materials: Employer Welcome Kit This kit contains information you can utilize to design and manage your HSA program. • The Employer Guide provides in-depth step by step instructions for implementing your HSA plan with HSA Bank • HSA Plan Design Tips • Employer Site Instructions, including an explanation of our employer contribution options Pre-Enrollment Phase We will provide you with valuable resources to educate your employees prior to enrollment. • HSA Fact Sheet • HSA Brochure • Web tools, including Is o~2 HSA Riglzt for Me?decision tool • Educational PotiverPoiut and Adobe Flash° presentations available for download Enrollment Phase During the enrollment phase we will keep you and your employees informed. • Employee communications covering how to enroll and what to expect in the mail. • Samples of employee and employer email notifications • Sample employee Welcome Kit Post Enrollment Phase Once the account is open, we are committed to educating your employees on their accounts. Monthly communication materials are available for your employees regarding pertinent information to make them better healthcare consumers and to maximize the benefits of their account. These materials are provided by HSA Bank on a monthly basis far distribution to your employees. Presentations HSA Bank offers several different types of presentations, including webinars, Adobe Flash, and PowerPoint. Webinars HSA Bank offers webinar sessions throughout the year. These sessions focus on HSAs, employer options, and HSA Bank services. Sample topics include: • Why choose an HDHP and HSA? • How to design plans • What is an HSA? • How to use an HSA Customized webinars are also available by contacting HSA Bank's Business Relations Coordinators. Adobe Flash Presentatians HSA Bank's Adobe Flash presentations provide general. information on HSAs and HSA Bank services. HSA Bank's Adobe Flash presentations are available for download from our website. -27- PowerPoint Presentations HSA Bank's PowerPoint presentations outline the benefits of HSAs to employers and their employees. An overview of HSA Bank's capabilities and services are also provided. Informative Website HSA Bank's website is an invaluable educational resource providing information from the basic HSA concept to the actual legislative text that created HSAs. HSA Bank's website has a glossary that defines insurance and banking terminology. The website also provides users with several media, such as PowerPoint and Flash, to learn about HSAs using the method with which they feel most comfortable. Online Decision Support Tools Is an HSA right forme? Calculator HSA Bank created a calculator to weigh the benefits and costs of a traditional health plan as compared to an HSA-compatible health plan. The calculator takes the information provided and determines the cost of each plan. It also describes some of the benefits that an HSA plan offers. Alternatively, ahard-copy worksheet is also available for calculations. Future Value Calculator HSAs provide the funds employees need for their health care expenses of today, or tomorrow. HSA Bank created the Future Value Calculator to estimate the value of employees' HSAs, the tax savings on their contributions, and tax-deferred growth based on the information they enter. -28- ~°~ - Employee Contribution Options HSA Bank makes it easy for your employees to make contributions. Your employees can contribute to their HSAs through payroll deductions if you offer a cafeteria plan, directly through HSA Bank's online contributions system or by check. 1. Online contributions: The online contributions system is available in HSA Bank's Internet Banking system. Prior to making contributions, your employees must link to a bank account in order to transfer funds to the HSA. Instructions for setting-up an external account are available at ~~./,u~i~.(k:~ri1?r~l<.L~,~~~l4f~c~€~~~er~t~;lcc~stt~~ibt~tia~rt i~~st:-~~~:tti>~~~.ls~i['. 2. Check: Your employees can submit a check and contribution form to HSA Bank. Account Options Bank Account All accounts with HSA Bank are opened as interest-bearing bank accounts, which are FDIC-insured through Webster Bank, N.A. The interest is calculated on a daily basis and credited to the accounts monthly. HSA Bank uses a tiered rate structure, with applicable rates determined by the daily balance maintained in the bank account ~~ ~`" throughout the month. The rates are based on the Annual Percentage Yield (APY) and are subject to change. Fees may reduce earnings. Please refer to www.hsai~ank.coin for current rates. Investment Accounts For your employees that would like to invest their HSA funds, HSA Bank offers two self-directed investment options - a TD Ameritrade Corporate Services investment account or Mutual Fund Selection investment account. TD Ameritrade Corporate Services A TD Ameritrade Corporate Services investment account provides your employees with access to stocks, bonds, and over 11,000 mutual funds. HSA Bank has no minimum account balance requirements for participation in this service. However, TD Ameritrade Corporate Services may have minimum trading requirements far a specified fund or equity. HSA Bank does not charge a fee for this option. Trading fees may be applied by TD Ameritrade Corporate Services. You or your employees can obtain more in-depth information about the TD Ameritrade Corporate Services investment option at ~_>~~~_isa i~_z~,a_'sti t ~r; "'..t.'c t4i a,.d~~~ (cii~i~e. i°»j,i~. Opening a TD Ameritrade Corporate Services Investment Account Your employees can open a TD Ameritrade Corporate Services self-directed investment account for their HSA in three steps. Step 1: Go to _ _ Y.i:. E~E?<as~i~..cc_r~a~. Under the Prod~sct Services tab in the main navigation, click on TD Ameritrade from the menu under Investment Options. Step 2: Complete the TD Ameritrade Corporate Services application, which is available for download at I~tt,; ``!~,~-°~~ ~~~ ~,~<~1~f~~l .~°c,rt~1~(~>~_«~~~~~~~4%dt~~~c~rii~':tcl~..r~~l€€'. Open the PDF version of the application where prompted. Your employees may type their information into the PDF application and print it out, or print the application and hand-write their information. Step 3: Fax or mail the application to HSA Bank. Afte~• completing the TD Ameritrade Corporate Services application, your employees may fax it to HSA Bank at 1-920-803-4184 or mail it to the address listed on the application.. After the application has been processed, the employee will receive a TD Ameritrade Corporate Services Welcome Kit within five to seven business days. -29- Mutual Fund Selection A Mutual Fund Selection. investment account provides your employees with the option to invest in ten historically high-performing mutual funds. HSA Bank has no minimum account balance requirements for participation in this service. HSA Bank does not charge a fee for this option. The Mutual Fund Selection investment account vendor charges an annual fee of $24; however, your employees are not charged any trading fees. You or your employees can obtain more in-depth information about the Mutual Fund Selection investment option Opening a Mutual Fund Selection Investment Account Your employees can open a Mutual Fund Selection Investment Account for their HSA using the following steps. Step l: Login to HSA Bank's Internet Banking system at 1~~°~~?~:r1~~~~=~.~~s~~~6~~ ~l,t~~~~~~1<<ci~~~~~l~h_~~~~i_~~~n~. If the employee does not have an Internet Banking login, he or she can sign up for Internet Banking at: ~?``t~ .,`+ i~`+C.C'CCit 11tiif~~ 4~Ik.~'(:3tYlr~1~1<Ill~ ll]~Y ~rl',Ta}1 iYlt;t.'Cl °,tClifl~~ ~4i _'11i2 3 t3tiVa t^; :t~.. _..._._..1 ----.._ ....__. .. ._.._.__ ..---- ...c..--- -~~ --._. _.._.---... _.._.__..._-.~.~______ .._~--._. Step 2: Once logged into HSA Bank's Internet Banking system, select the Investments link from Accocrnts heading in the main navigation menu. Step 3: Click on the h7vestnTent Options button at the bottom of the Investments page. Step 4: Click the Mi~ctunl Fund Selection Enrollment link next to the HSA account number to link the investment account. Within one business day, the employee will receive an email that includes his or her Personal Identification Number (PIN). Your employee will need this PIN to sign into his or her Mutual Fund Selection Investment Account. Then, one or two business days Later, the employee will receive another email that provides the account number and information on how to access the investment account. Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by, the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA. -30- Distributions HSA Bank provides your employees' with several options to access their funds to pay for qualified medical expenses. The i~~~;~_6_!_t7i= f~~_t_.; and the 11~ ~_ tf?_~°c ~i,,,z_,1; provide immediate access to the HSA funds. A ~~1~t~~~_~:~1 ~'w it;i~f€t,tt_~F l~=... ~Ft~~~ can be utilized to withdrawal funds from the account by receiving a check from HSA Bank. Qualified Medical Expenses HSA funds are always tax-free when used to pay for qualified medical expenses. The Internal Revenue Service determines what constitutes a qualified medical expense. A list of qualified medical expenses is available on our website at Iattt?:r:rbr _~~_i~,<~I}~z.~h.c~'~~~ix`~~~!.~.~;`~~~~~3i~_E eti~?~~n~,c~,.~. A partial list of Qualified Medical Expenses i~rcludes: A partial list of items that are not Qualified Medical Expenses i~zclude: Weight loss pros rams Athletic cluir meanbership Cosmetic ;~u•gery flealtl7 1?rogranis offered by resort hotels. 9~eatth elulis ~~ ~7yms Si:ientolc>gv°' counseling Special foods and beterai~es Distribution Options To maximize the convenience of using the HSA, your employees are provided with several ways to access their HSA funds: 1. Dehit card: HSA Bank offers an HSA Visa° debit card. If ordered at HSt~ r s, a na €c the time of enrollment, the debit card is provided at no charge. A fee ~,~~: may be charged to renew the debit card or if the card is lost or stolen. u Please refer to your HSA Bank fee schedule to determine the correct fee. _ ...''. This card provides access to the HSA funds at point-of-sale and ATM ~'t~ cash withdrawals. Point-of-Sale (POS) purchases can be signature- or ~ -°- PIN-based transactions. The PIN-based and ATM transactions have a fee. Signature-based transactions have no fee. Pharmacies and providers can run the payment like a credit card transaction if a PIN is not entered. Payments made by sending in your card number to the service provider are considered POS withdrawals and do not have a withdrawal fee. Multi-purse debit card options are currently pro~rided through Evolution Benefits and MBI (a Metavante company). Evolution Benefits provides real-time substantiation of prescription drug transactions. Evolution Benefits has direct data links in place with premier pharmacy benefit managers (PBMs) including Medco Health, Caremark Rx (Advance PCS), Express Scripts, Argus, and Medlmpact. Real- time substantiation occurs during the card swipe authorization in the pharmacy prior to the transaction being approved. The BennyTr'' transaction is matched to the claims data at the point-of-sale; if they match, the card swipe transaction is approved and considered 100°lo substantiated and requires no further action. MBI supports real-time claim feeds from three of their PBM vendors; Caremark, Express Scripts, and Medco. Checks: Your employees can write a check to a provider to pay for qualified medical expenses or reimburse themselves for expenses already incurred. Employees can purchase a book of 50 duplicate checks. Withdrawal requests: Your employees can submit a withdrawal request to HSA Bank. HSA Bank will then send the employee a check for the disbursement. HSA Bank charges a fee to process withdrawal request forms. -31- Debit Card and Checks Fraud Protection HSA Bank is committed to keeping your employees' HSA funds safe from fraudulent withdrawals and employs several security features for debit cards and checks, including: Merchant Restrictions HSA Bank restricts the Visa ~t debit card to only be accepted at medical service or product providers (doctor's office, pharmacy, medical supply store, etc.} and ATMs. Individual PIN Selection Your employees select their own personal identification number (PIN) during the debit card activation process. Additionally, they can change their PIN at any time by calling 866-985-2273 from their home or business telephone. Transaction Amount Limits HSA Bank limits all ATM or PIN-based debit card transactions to $300 per day. Also, all signature-based debit card transactions and check transactions are limited to $2,000 per day. If your employees require their transaction limit to be increased temporarily, they can contact HSA Bank's Client Assistance Center at 1- 800-357-6246, Monday through Friday, 7 a.m. to 9 p.m., CT. Lost or Stolen Debit Card Notification If your employee needs to report a lost or stolen debit card, you can contact HSA Bank's Client Assistance Center at 1-800-357-6246, Monday through Friday, 7 a.m. to 9 p.m., CT. If your employee discovered the card lost or stolen outside of HSA Bank's standard business hours, they may contact our debit card processor at 1-800-523-4175. -32- Account Access & Maintenance Internet Banking (Employee} HSA Bank provides your employees with 24 hour-a-day, 7 day-a-week access to their account information through our InEernet Banking system. HSA Bank`s hmeniet Banking system allows them to: • Update your contact information, including your address, phone number and email address • Change your Internet Banking system password • View your current acco~mt balance, transaction history and check images • Transfer funds from an external bank account to your HSA • Transfer HSA funds to and. from your HSA brokerage account • Sign up for email. alerts for contributions and distributions • llownload your account information into Microsoft Money or Quicken • View statements and [ax documents electronically • Access health care resources Following are step-by-step instructions on how to use HSA Bank's Internet Banking system. How to Update Contact Information Step 1: Log into HSA Bank's Internet Banking system. Step 2: Place the mouse over Profiles in the main navigation menu to view the drop-down menu. Select Change ~ cJruicC't lrt~l~~ r'nuiiGit. Step 3: Select the account to be updated. Step 4: Enter- the new contact information. Step 5: Click the Update hi foP•rncation button. How to Change the Password Step 1: I,og into HSA Bank's Internet Banking system. Step 2: Place the mouse over Profiles in the main navigation menu to view the drop-down menu. Select Clucnge Password. Step 3: Enter the ctu7-ent password in the Old Pusswuril field. Then enter a new password into the Ne~ti• Pus•stivord field. Re-enter the new password in the Confirm Pati~stivord field. Step 4: Click Chance Password. How to Access Account Information Step 1: Log into HSA Bank's Internet Banking system. Step 2: Place the mouse over Accorcnts in the main navigation menu to view the drop-down menu. Select Health Suvirags Accatnit or Investment Accounts. Step 3: Cfick the account number to access the account summary. How to Set-up and Make Online Transfers Instructions ott how to set-up <<;~d m~~ke online transfers are available at: ' .~ -33- How to Sign Up for Email Alerts Step 1: Log into HSA Bank's Internet Banking system. Step 2: Place the mouse over Tools in the main navigation menu to view the drop-dawn menu. Select E-rr2uil Notifi~cutions. Step 3: Check the box in front of the notifications the employee would like to receive. Step 4: Enter the email address the notifications should be sent to. Step 5: Click the Submit button. How to Download Account Information I '~ Step 1: Log into HSA Bank's Internet Banking system. Step 2: Place the mouse over Tools in the main navigation menu to view the drop-down menu. Select Download Acti~~it}~. Step 3: Select the account to download, the program format, start date and end date. Step 4: Click the Click Here tv Doscnlvad button. How to Access Health Care Resources Step I: Log into HSA Bank's Internet Banking system. Step 2: Place the mouse over Tools in the main navigation menu to view the drop-down menu. Select Re.rorrr•ces. Step 3: Click the health care resource the employee would like to access. How to View Statements Online Step I: Log into HSA Bank's Internet Bankin!~ system. Step 2: Place the mouse over E-Dcx•runerazs in the main navigation menu to view [he drop- down menu. Select E-Stutertaerrts. Step 3: Select the account to view and click the Select Account button. Step 4: Select the month of the statement to view and click the Viesv Stuterrtent button. How to View Tax Documents Online Step I: Log into HSA Bank's Internet Banking system. Step 2: Place the mouse over E-Docarrnerats in the main navigation menu to view the drop-down menu. Select Tux Dc~c tunents. Step 3: Select the account to view and click the Select Account button. Step 4: Select the link with the year your employee would like to view. -34- e Employer Site HSA Bank recognizes the role you play in the HSA process. The employer login section on our website allows you to setup and administer your employees' HSA enrollment, view your employee list, make contributions to your employees' HSAs online, upload contribution data, and sign up for employer updates. You may also download HSA Bank's Employer Communication Kit (details available on page 26). --a ~.: _ `~ K Nlelcome ~ Cc>n[ect us ~ Click Flere Co L„<rott ~. tlL~ l' ~ Prafi€e Administration Contributions Resources Group on€ine Enro€€ment Welcome ''.. HS=.l=enl' Cr031EC this C9dIC3fed Bl7ipl~J t'r Slte t0 ITl3F':e ni3n 3!~In C~ and 3dntll}I Str3tin~ 3n H$~. irCyr3n} f01' ~OUr e'n}plC,~ees 35 E36j' and ~orr,enient as possible. ~>.II the to. Is uu a~ill Head are found in the A;IIO~=Zing fi~;e headings: Pt,tlle: -.Iloars -xl ~oae-:; ai}~, edit profile mLlmation. including Ganging ;our pass~t-ord. updanng;our personal I?references. 3nd updatimg contaK information fur ;ou and ;our eniplo:: e'r. ~;minisir;ticn: °II ads ;ou t~ re~~.ie:v~ all administrative user permissions and manage ;'our en}plo~ees~ HS~.list ~n~itli HS.-. Bari:. ~~:,rtEribut€uns: -ssists ,ou in managing contributions to ;your employees HS.=s throuoh our online contribution feahue. cgntribution file ~ upload pn?cess. or by seroCing a contribution b~; el}ock Resa;ires: s;::_ess resources pro:,idad b> HS:. Ban4'. to educate „otu emp!-o;aes about HS.-s anC hca~ too consuma health rare. s GI*ou~~ Ordine C-nr:dlment: Sc't up >~cur cusUOm online enrollment Ifuu naed an; assistance. please contact our Cedicatetl business Relations Coordinators at 1-86d3? c-2`sz. Hen} e ~F .. ~. 'CS^.. ~{ -35- Customization Website & Marketing Material Customization Options HSA Bank offers many Website and marketing material customization options for you to choose from. To assist you on selecting the customization options for your organization, HSA Bank provides a customization guide and order form at www.hsabank.com/documents/eustomization_guide.pdf. Applicable customization fees are also listed in the customization guide. Below are brief descriptions of the customization options we have available: Website and hyperlinks: You have the option of customizing HSA Bank's informational Website and links for certain applications. You are offered three levels of customization for the Website and hyperlinks, which are: 1. Tracking 2. Basic customization -includes your logo and color scheme 3. Full customization For more information on HSA Bank's Website and hyperlink customization, please consult the customization guide or contact our Business Relations Coordinators. Marketing materials: HSA Bank's brochure can be customized to include your logo and contact information. The content may also be customized to meet your needs. Enrollment materials: HSA Bank's enrollment options can be customized at the tracking or basic customization level. Welcome kit: The cover letter of the welcome kit can be customized to include vour lobo, specialized account detail, and specific contact information, such as a dedicated toll free number. v Monthly statements: Monthly statements can be customized to include your logo and contact information. Unique messages can also be incorporated into your employees' statements. Toll-free number: You can have a unique toll-free customer service number for your organization. This option allows for customized reporting of performance measures, such as average wait time, speed to answer, and call volume. Debit cards: There are two customization options to choose from. The basic option allows you to place your logo on the HSA Bank card stock. The advanced option allows you to design your own private-label card, purchase the custom designed card stock at cost, and issue the custom cards to your employees through HSA Bank. When setting up either custom option, you will also have the opportunity to customize language for the debit card and PIN mailers. Training and education materials: You have access to training and education resources, including: webinars, Macromedia°" Flash animation presentations, and PowerPoint presentations. All can be customized to meet your organization's needs. -36- Reporting Employer Reports Due to confidentiality regulations, HSA Bank cannot report individual HSA statistics. However, HSA Bank provides monthly reports on the average ba}an contributions, distributions, and utilization of account options, which is based on the aggregate data of your employees upon request. Additionally, HSA Bank's Employer Administration Area allows employers tc view an employee list, upload contribution data, submit contributions online, and sign-up for employer updates. If you sign-up for group online enrollment, the administration area also allows you to monitor employee enrollment, add eligibility questions and view enrollment reports. Custom reporting would be considered upon request. If you are interested in requesting a custom report, please contact HSA Bank's Business Relations Coordinators at 1-866-357-5232. tmp~oyee tteports HSA Bank provides several reports to the accountholder to assist them in managing their HSA, including: • Account Statements -provides account information and transaction history. Monthly e-statements are also available through the Internet Banking system. • Yv!~r-Er?clS'tarsfs Report -provides participants with their account activity fnr the calendar year, inclr~ding total contributions. The year-end status report also provides instructions and refers them to the forms they need for filing their HSA related tax information. To determine the amount of contribution to deduct, the employee will use the total contributions provided on the year-end status report and the pre-tax contribution amount provided on their W-2 form from their employer. • IRS Form 1099-SA -provides the distributions that were made from the HSA. Participants would receive a separate 1099-SA for each type of distribution utilized. The five types of distributions are: normal, excessive contribution removal, death, disability, and prohibited transaction. • IRS Firm 549&-S.9 -provides the amount of contributions made during the tax year. Since HSA participants have the right to make contributions to their HSA for a tax year until. April 15 of the following year, this form is sent in May of the following year. -37- ,~ ,~;. f~ ~' ,. ,. _ n.~. Business Relations HSA Bank's Business Relations Coordinators are exclusively dedicated to assisting our business partners. They strive to make offering HSA plans to your employees cost effective, convenient and easy through high-level., personalized service. Here is a sample of what is offered: Pre-Enrollment • Custom Plan Design and Communication Tips _~ ~~ Based on a series of questions asked by your Business ~ ~ x Relations Coordinator, specific recommendations ~~ regarding plan design and tips for presenting the HSA offering can be provided. You will need to provide ~~~- ~` information such as number of employees, other non- HSA compatible plans that ttre being offered, your i ~` objectives for offering the HSA plan, premiums and the ~~ amount you plan to contribute to the HSAs. ~ ~' • Customized Service When you select HSA Bank as your HSA administrator, y you and your employees receive the best customer care _, in the industry. Service is customized to fit your needs and a team is assigned to support you every step of the way. e Tmplerp,entatinp: Assistance o Group Online Em-ollment, Group Online Contribution and Employer Site de-nonstrations. o Lttrge Group Transfer Facilitation -- If your employees have HSAs with another administrator and you would like to transfer them to HSA bank, call Business Relations and mention the group transfer to receive a setup fee waiver and ask about pre-filled form options. o Communication Kit summary and Usage Guidance Enrollment Em-olhnent Status Reporting Through Group Online Enrollment Education and Enrollment Assistance far your Employees including: o ~'ebinars--Live, remote sessions with a $usiness Relations Coordinator o On-site educational sessions provided by a member of your Regional Account Support Team (availability may vary). Ongoing • Email-Based Convrtunication Reminders and Updates Plan Design Evaluation • Customization Assistance HSA Bank's Business Relations Coordinators are available Monday through Friday, 7 a.m. to 7 p.m., CT. You can call them at 1-866-357-5232 or email businessrelations@hsabank.com. Client Assistance Center HSA Bank's Client Assistance Center is dedicated exclusively to supporting HSA administration., and designed to help your employees with any questions, either prior to enrollment or once an account has been established. The Client Assistance Center representatives are experts in HSAs and can answer all HSA-related questions. The Client Assistance Center representatives are available Monday through Friday, 7 a.m. to 9 p.m., CT. Your employees can call them at 1-800-357-6246 or email askus@hsabank.com. Spanish Materials and Support HSA Bank's comprehensive brochure, enrollment forms and account maintenance farms are available in Spanish. To request these materials or for assistance with a question, you or your employees can contact an HSA Bank Spanish Language Representative at 1-866-357-62 ~2, Monday through Friday, 8 a.m. to 5 p.m., CT. HSA Bank is a division of Webster Bank, N.A., member FDIC -38- HS~ Ba N Kg Employer Sign-Up Form ~Vaf~nrrd{ I cads-r m tie:+(t It Saern,q; .^}; r~nentti + II ~ n/ Y.._F-:~ :p t irk For HSA Bank Use Only Affiliation Code AIN Marketing Code ~ BP ID Instructions: All fields are required unless otherwise noted. Please complete this form using your computer, or print clearly, then fax the completed hard copy to Business Relations: (920) 803-4184. Be sure to keen a copy of this form for your records. You will need vow' username to loin to the Employer Site. By completing the Employer Sign-Up For/tt, you will gain access to HSA Bank's Employer Site, which is designed io help you manage your HSA program. You can also make online contributions to employee accounts through this site. A summary of your enrollment and contribution options will be emailed to you along with your temporary password, in approximately 3 business days. If you have questions, please contact us by calling the toll free Business Relations number, (866) 357-5232, M- F, 7 a.m. - 7 p.m. CST. Company Information Company Name t O ~ h lJ~., f Benefits Eligible Employees # of HSA Eligible Em yees # of Employees in the Group Fed ral Tax ID # # o e a ~ ~ ( ~ t-I- O'er Address O ~ -~- - City ~ Q ~ ~ State Zip ~ L~-1"~ ~~„ 44 „ Phone L_~ ~ ~ Fax ~ - © - ~ ~ ~ Business Type ^ Sole Proprietor ^ Joint Venture ^ LLC ^ Partnership ^ Trust ^ C Corporation ^ S Corporation ^ Non-Profit ^ Association/Cooperative Other Main Administrator Information First Name Last Name i Email ~, ., ~ I~ ~. ~ ~- C c - y ~ . ~ I ~ ~m b i c~ ~ / ~ Phone („ ~ - r o ~ - I ~i ~ Ia,L~~~ Fax ~JJ `~ C~ - r_~ - , "-' ' _~ ~~ Select User Name Extension ~ urin. 8 ehrrrirr.Yr~rs, _ !clleGC <~ urrnrbr~rs anh~ The first 8 letters or numbers are required. (Your username will be case sensitive.) You will need your temporary password, which will be emailed to you, and your username to log in to the Employer Site for the first time. You will then be prompted to change your password. Important note: The Main Administrator is the only individual that will have full administrative rights to add other administrative users and assign rights for accessing or updating your account. If you wish to change your Main Administrator in the future, you must complete a Company/Main Administrator Update Form, which can be requested by calling Business Relations at (866) 357-5232. Privacy, the USA PATRIOT Act, and the Emplo~r Site At HSA Bank we respect and protect the confidentiality of customer information. Some of the information we request is required by a Federal law called the USA PATRIOT Act and regulations adopted by governmental agencies to implement it. This law requires HSA Bank to obtain, verify and record information that identifies each person or entity that opens an account. This information helps the government fight the funding of terrorism and money laundering activities. When you sign up for the Employer Site, we will ask you for your company's name and address. We will also ask you for an identification number such as your Socia] Security, EIN or Tax Identification number. This information will allow us to identify you. In some instances we may also ask to see identifying documents. Please rest assured that all customer information is kept in the strictest confidence, unless required by law to be disclosed. -s . ~,.. ~, r !r rr ~.: (IIIIIIIII'I~~II'llll~'IIIIII ~r-~/T~l ~~ l~ ~ tb~Lrrl~j ~~(;~(~( )S C~IYI Q.S"1 - ~'l.X~ FORM_ERSignUp_0308_V3 (1215/2008} Wendy Eckert -Group Online Enrollment Setup Confirmation Page 1 From: <autoemail@hsabank.com> To: <Wendy.eckert@ci.columbia-heights.mn.us> Date: 12/2!2008 11:43 AM Subject: Group Online Enrollment Setup Confirmation C. SET-UP CONFIRMED .~ Thank you for choosing HSA Bank for your Health Savings Account Needs Your information has been submitted successfully. Below is your unique link which can be posted to an internal website or given to your employees directly to enroll in their health savings account, If you have problems accessing the Zink, please contact our Business Relations Department at 1-866-357-5232 Monday Through Friday, 7 a.m. - 7 p.m. CST https://secure. hsabank.com/grou p_enroll ment/enrollment.aspx?id=416005069 Summary of options chosen Enrollment Process: Approval Invoicing Selections: Setup fees paid by Employer Monthly fees paid by Employee Check fees paid by Employee Start Date of Enrollment Period: 12/02/2008 End Date of Enrollment Period: No End Date Next Steps 1. When using the Immediate and Batch processing methods, you must upload a census fill before vour employees can use the enrollment link. Go to 'Group Online Enrollment' in the main navigation of the employer site, select 'Administration', and select 'Unload Census File'. A sample file is provided. 2. Provide the above link to your employees for enrollment. Enrollment communication and instructions for your employees is available under Resources and then Training Resources. 3. Monitor the progress of your enrollments by clicking on Group Online Enrollment and then Administration. you have selected By approval, the Administration area will be used to approve your employees. For detailed instructions on how to use the Group Online Enrollment area of the Employer site, please log into the Employer site, select Group Online Enrollment in the main navigation and select Instructions from the drop down. Group Online Enrollment Instructions It takes Just four easy steps to enroll in a Health Savings Account using HSA Bank`s Group Online Enrollment system. Simply use any computer, any time, and follow these instructions. Step 1: Type or copy and paste this customized enrollment link into your Internet browser/address bar: https://secure. hsabank.com/group_enro l l mentlenrol l ment.aspx?i d=416005069 You will be taken to an enrollment page created specifically far your group. Enter your Social Security or Tax Payer Identification Number and click Submit. Step 2: Complete the online enrollment application. You will need to supply the following information: ~ Effective Date of your Health Plan ~ First and Last Name ~ Home and/or Business Phone ~ Date of Birth ~ The Deductible for your Health Plan ~ Street Address (P.O. boxes not accepted) ~ Email Address ~ Citizenship Status ~ Employer Information You will also be able to order checks and one complimentary Visas debit card, sign up for Internet Banking and designate an Authorized Signer. With Internet Banking, you have 24 hour a day access to view account details, access statements and tax documents, change your address, sign up for email notifications, and opt to receive electronic statements. If you would like to add an Authorized Signer, you will need to provide their: ~ First and Last Name ~ Street Address ~ Phone Number ~ Date of Birth ~ Social Security Number Identity Verification Note: In order to comply with the Customer Identification Program (CIP), regulation 31 CFR 103.121, and section 326 of the USA PATRIOT Act, we must gather information for identity verification. This means that when you open an account, we will need you to provide the information as noted above for you and your Authorized Signer (should you choose to designate one). If your identity or the identity of your Authorized Signer is not verified by our automated process, you will receive a letter from us requesting additional information. Step 3: Your employer must log in to the employer site and approve your application. Your account will typically open in 1-2 business days. You may wish to talk to your employer to determine if they wouici 'like you to notify them after you complete the online enrollment process. Step 4: A welcome kit will be mailed to you in approximately 7-10 business days after your account is open. This will contain important account information. To optimize your HSA benefits, please review it carefully. -: BA N Kg ,. •ur,r! (~. ~.iri!~. irr t h ., !+h ':.n in~•~ Y: ~ vu;: F, One Choice Stands Out... tf you have questions, please contact ($00} 357-6246 Monday - IYiday, : n.m. - `) p.m., Central Timo or email aslcus~~hsabank.com Health Savings Account Interest and Fee Schedule Huw We Determine tl:e Lrterest Rate We use the daily balance method to calculate the interest on yow accowtt. The daily balance method applies a daily periodic rate to the principal in the accowtt each day Interest is compounded monthly and credited monthly. Interest begins to accrue no later than the business day that we receive credit for the deposit ofnon-cash items (for example, checks). The interest rate and annual percentage yield (AP`n is based on the balattce in your account. The interest rate and annual percentage yield available on yow account, as of December 2, 2008 is as follows: Interest Rate' APY For daily balances of $15,p00.~ or more: 2.71 % 2.75°k For daiTy balances of $5,000.00 or greater and less than $15,000.00: 1.98°~ 2.00°k For daty balances of $2,500.00 or greater and less than $5,000.00: 1.63°k 1.65% For daNy balances of $500.00 or greater and less than $2,500.00: 0.99% 1.00% For daily balances less Than $500.00: 0.99°k 1.00% 'This Interest Reta is subject to change, at our discretion, at any time. Fees may reduce earnings. Current interest rate and annual percentage yield information is available on our websde www.hsabank.com or by calling 800.357-6246 Additional Fees and Terxrs for this Account • You will receive a periodic bank statement [f you request a copy of a check the cost is $4.00. Accowti balances and activity arc available 24-7 via atoll-free Bankline service or internal banking at no charge. • There is no charge for point-of--sale (POSj purchases using your signature. A fee of $2.00 will be imposed for each ATirl widtdrawal or POS purchase using your P[N. This fee wilt be deducted from yow bank account. • Your debit card renews automatically every four years. A fee of $6.00 is deducted from yow bank account for each debit card renewal. A fee of $12.00 is imposed for lost /stolen debit card replace- ment HSA Bunks rrserves the right 1o cancel i+our debit curd nccesa nl nrry time. Sbu mart rrhnr yzrur rk~bit eurri/sl to HS~f Bunk'g' uprm demand. • Checks are optional at a cost of $7.95 for 50 duplicate checks, which includes t 0 deposit tickets. Checks mutt be used for normal distributions only. Withdrawal fomu are also available for use. A processing fee of 510.00 will be imposed. Submit a withdrawal form and the ba»k will send you a check. If9rlxhzrwal firrnrs nn nruiukrtorvfirr rhefollowing distributions. death, disuhilrtu pmhibited and ezcesr cnntrihuriorr rnmmnl (525.(10 Kcees cnnn•iMrtirnr rx:errnvul jre cgrplie_s!. • A maintenance fee of $1.75 will be imposed every month if the balance in the account falls below 53,00(1.00 on any day of the month. This fee will be deducted from your bank account • [f you close your HSA, interest that has accrued but I>as not yet been posted cvill not be paid. For more details regarding the general terms and conditions that apply to yow HSA, please see the Deposit At;count Agreement and Disclosures for Health Saving Accowtts. HSA Bank is a division of Webster Battle, N•A., Member FDIC Service Fees ERective August 1, 2008 Set-up Fees Bank Account (6asea on errrollmenr mernor>) Handwritten Application ................................ $22.00 Online Enrollment ..................................... $10.00 Monthly Fee Monthly Bank Account Fee (waived on barances o($3.000 or more) .... $1.75 Services Included in Monthly Fee Initial debit card at account opening (up to 2) Debit card point-of-sale purchase via signature Unlimited check transactions Contribution processing Monthly e-statements/Quarterly paper statements Tax reporting (year-end status,1099-SA, and 5498-SA) Online account access Bankline (800-565-3512) Specialty Services Fifty HSA Checks (inducting ten deposit tickets) ................... ... $7.95 Monthly paper statements (per month} ....................... ... $0.75 Four-year renewal per debit card ......................... ... $6.00 Replacement of lost debit qrd (per card) .................... .. $12.00 Termination of debit card access (percent} ................... .. $12.00 Per PIN withdrawal (ATM orpoint-or-sate} ...................... ... $2.00 OverdrafUNSF per item drafted against HSA ............... .. $30.00 Process manual withdrawal request ...................... .. $10.00 Request copy of check, s+~tement, or tax documents ........ ... $4.00 The following services are charged per occurrence: Close account fee, Excess crontribution distribution, Deposited item returned unpaid to us, Wire transfer sent or receive, Stop payment requests per item, Request copy of debit card transaction merchant receipt, Corrected IRS filing fee (non-bankurg arrw) ....................................... $25.00 FEES ~eSC175 S3 1208 HSA Bank -National Leader in Health Savings Accounts: City of Columbia Heights Online Enrollment Page 2 of 3 HS~BANK` ~' i!S 7?f~ ~t. 'ic`.'" I' fFr~,ri' Y,ul'2i;r :~.°-C.i ~t~l7 t~. ~S c;~~rtsz;,xr sit ,`:~+:~~ , ,~ ~,F,,p ,','.%s., ~fe:mL-~sr ~ GEC" Group Enraflment ~en/ices City of Columbia Heights x~- ;~~ Friday, March 6 HSABank.com Resources Welcome to HSA Bank Group Online Enrollment HSA Information This service is provided for the employees of City of Calumbia Heights. If you are • What is an HSA? currently not employed by City of Columbia Heights, or if you do not recognize the Frequently Asked Questions company name, please contact your employer to confirm that you are using the (FAQ) appropriate link to enroll in your Health Savings Account. Calculators If you recognize the employer listed above, then please review (1) the following • Is an HSA Right for Me? information about items needed to enroll online and (2) a short overview of the account • Future Value of HSA fees. Manage Your Account IMPORTANT: REVIEW THE REQUIREMENTS BELOW BEFORE STARTING • Account Options • Login to Account The following is a list of the items that we require you to have in order to enroll online. • Sign-up for Internet Banking r x~. The enrolirfierit pl"ocess cannot be COmpteted if you are missing any o. ~~~ese items: • Online Forms ^ Cookies must be enabled on your computer (What's this?) ^ Form of Identification -Optional (Drivers License, State I.D. or Passport I.D.) ^ Basic health plan information (effective date and deductible) ^ Employment information (Employer Name, City and State, your Job Title/Profession) ^ Authorized Signer Name, Social Security Number, Date of Birth, and Residential Street Address -Optional (If you want another person to be able to debit your account and receive account information. If you designate an authorized signer on your account, all fields are required to proceed.) ^ If you have power of attorney privileges over another individual and are opening this account on that individual's behalf, you must complete and submit a paper application and a power of attorney addendum. Please contact HSA Bank at 800-357-6246 for information and to obtain the necessary forms. ®nline Enrollment Fees ^ $7.95 Check Order (Optional) ^ $1.75 Monthly Service Fee Enter Your Social Security Number or TIN Below to Begin -~ Submit If you have any questions or require assistance throughout the enrollment process, please contact one of our client assistance center representatives at 1-800-357-6246, Monday thru Friday, 7 a.m. - 9 p.m., CT. Please Nate: Your account will not be submitted if you close your browser window at any point during the enrollment process. doing so will terminate your current session and you will have to start the enrollment process over from the beginning. Please Note: Only persons with Social Security Numbers ar Individual Taxpayer Identification Numbers that we show as linked to the employer are eligible to use this service. If you are denied access, please contact yaur employer to have your SSN added to their list of eligible employees. COPYRIGHT ©2008 -HSA BANK. ALL RIGHTS RESERVED. https://secure.hsabank.com/group_enrollment/enrollment.aspx?id=416005064 3/6/2009 Employer Quick Reference Sheet 1 Complete the Employer Sign-Up Form (Step 1 of the Five-Step Sign-Up Process) • Go to wrww.hsabank.com • Point to the Employer heading • Select -Employer Sign-up • Complete Employer Sign-Up Form & return to HSA Bank via fax or mail • Maintain a copy for your records. (You will need your username to log in to the Employer Site.) • Welcome email will arrive in about 3 business days My Username (selected on ER Sign-Up Form): Password - Emailed to you once your sign-up form is processed. You will be asked to change your password the first time you log in to the Employer Site. If you forget your password, visit has://secure,hsabank.com em layer Main~gasswc~rdRemind.asr~x (` Using the Employer Site & Considering Plan Design (Step 2 of the Five-Step Sign-Up Process) • Point to the Employer heading, select Employer Login • Enter your username & click Login • Answer the security question & click Continue o Enter your password & click Continue • Point to the Resources heading, click on Training Materials, select View HSA Program Design • Review Plan Design Tips & Program Design Article • Download & complete the Implementation Worksheet The Employer Site also allows you to: • View & make changes to your employee list • Download the comprehensive Communication Kit • View Employer Newsletters • Sign up for & access Group Online Enrollment (GOE) • Access Group Online Contributions (GOC) -separate sign-up process required Select Enrollment and Contribution Options - (Steps 3 & 4 of the Five-Step Sign-Up Process) Online options help protect employee info. (SSNs don't go through the maiij. I hey also save you time, postage, and paper. For details, refer to your em to er manual, available in our welcome email, on the Communication Kit CD and from the Em (o er website. ... a ~.. ,.. .. . Enrollment Contributions • Group Online Enrollment (GOE) Group Online Contributions (GOC) My Custom Group Online Enrollment Link: • ACH/Wire with data file • ACH push via payroll vendor • Electronic File Enrollment (ER initiated) • Paper • Individual Online Enrollment • Handwritten/Paper (higher set-up fee) IRS HSA Enrollment Eligibility Requirements & 2009 Contribution Limits - *HSA Bank cannot arovide tax advice. • Covered by an HSA-qualified Health Plan • Not covered under anon-HSA-compatible health plan • Not claimed as a dependent on another person's tax return (spouses excluded per IRS code) • Not covered under Medicare • Individual Coverage - $3,000 • Family Coverage - $5,950 • Catch up Contribution (for accountholders 55 or older) - $1,000 Resources IStea 5 in the Develop a Communication and Education Plan: • Review the Communication Kit: -Employer Relationship &HSA Program Design -Employee educational materials (HSA concept) -Enrollment (instructions, samples, What to watch for) -Post Enrollment (topics of interest to employees) - Spanish Materials (far employees) Review Implementation Worksheet recommendations • Develop a Communication & Education Plan (include the materials you will provide, timeline & method) • Is an HSA Right for Me? calculator www,hsabank.com/calculators/decision tool.as~x - Helps employees determine if the HSA-Compatible plan is the best choice for them. Future Value calculator www.hsabc€nk.com ccslcu~ators Future Value_css}~x - Provides specific examples of account growth. Contact Information - Website: t-:~,~r.~~saban.com Mailin Address: HSA Bank • P.O. Box 939 • 5hebo an, WI 53082-0939 ~a. __,~_ _._ ....,. _~,_ , a . nw.. _,_...,~ . _.a ...~m _ .~ . . _ .,_ .... ... ...... _..~ n _ .w.w.~_._ Business Relations Department (866) 357-5232 My Contact: Monday through Friday 7a.m. - 7p.m. Central Time Email: Client Assistance Center (Accountholders) (800) 357-6246 Phone: or (866) 357-5232, ext. (Spanish Speaking Accountholders) (866j 357-6232 =Fax: Monday through Friday 7a.m - 9p.m. Central Time dr.NK EMPLOYEE ADD/REMOVE FORM Instructions: Please fax this signed and completed form to Business Relations: (t)?t)18(1 y-~18=~ *Employees may only be added if they currently have an account at HSA Bank. Adding an emnlovee does not open their Health Savings Account; it links an existing accountholder to you. Those who wish to open an accattnt must submit an online or paper application. Removing an emnlovee does not close the HSA account: it removes the link between the Employer and the Employee. Employees nre not required to close their accaurtt if they leave their current employer or if tlYey no longer !rave an HDHP. If an employee wishes to close their account, they must contact our Client Assistance Center at (800) 357-6246, Mon -Fri, 7 a.m. - 9 p.nr., CST. If you are using the Group Online Contribution tool, removing an employee from your list will cancel their Pending Contributions. If you have questions, please contact Business Relations at, (866) 357-5232, M - F, 7 a. m. - 7 p.m. CST. Comaanv Information Company Name _ ~_ ~ _ __ Federal ID # For Internal $p ID# ~~~~~ _I~~~ 1__ .Use Only Do you pay the monthly maintenance fees for your employees' HSA accounts? ~ yes ~ No *If you are being invoiced, this form nztrst be submitted prior to the !5th to avoid being chnrged that month's fee for removed employees. Employee Information If you are adding or removing more than 3 employees, please attach a spreadsheet containing the noted information. FirstName MI Last Name -_ Account# ~ { i ~~~~ ~^~ Social Security# ~~~~ ~ ~~ Effective Date (mm/dd/yyyy) Must be on or after the date the fax is sent. m ~ m t wish to ^ Add ~ Remove the above employee to/from my Employee List. Removal Reason tIf Applicable) ^ Employment ^ No HDHP *Adding an employee will not open their account and retnoving will not close their account. See instructions. Status ^ Their Choice FirstName MI Last Name Account# ~ ~~~ Q,j2 Social Security# Effective Date (mm/dd/yyyy) Must be on or after the date the fax is sent. ~ ~ ~ ~ ~~ ~ ~ _ __ I wish to ^ Add ~ Remove the above employee to/from my Employee List. Removal Reason (If Applicable} ^ Employment ^ No HDHP *Adding an employee will not open their account and removing will not close their account. See instructions. Status ^ Their Choice FirstName MI Last Name --- - IJ-f~ OR Social Security# ~ ~~ ~ ~l I Account# L===~LZ~ _ Effective Date (mm/dd/yyyy) Must be on or after the date the fax is sent. m / C~ / ~L__~ I wish to ^ Add ^ Remove the above employee to/from my Employee List. Removal Reason (If Applicable) ^ Employment ^ No HDHP *Adding an employee will not open their account and removing will not close their account. See instmctians. Status ^ Their Choice Signature of Main Administrator Name Date L IIIIIIIIIIIBIIIIIIIIIIIII `""""""°"" J ~ .;~-rr.~~ ~- f; r ,' g ~~ .... l71'F' ~ ~.. c. ~ v ,~: ACH Process Instructions Please provide these instructions to your payroll service or vendor. Would you like to utilize your payroll service or vendor for ACH contributions? Through HSA Bank's Direct ACH option, you are able to utilize your current payroll service or vendor to make contributions to your employee's health savings accounts. As an added benefit, HSA Bank has developed a tracking mechanism to distinguish between employer, employee pre-tax through a cafeteria plan, and employee after-tax contributions. ~,-~___a_w~ ( ic~rli ~°l~i, I ring ~ ~iti~rl~ Field 1 2 3 4 5 6 7 8 9 10 11 Data Element Record Type Transaction Receiving DFI Check Digit DFI Account Amo~mt Individual Identification Individual Name Discretionary Addenda Record Trace Number Name Code Code Identification Number Data Indicator Number Field Inclusion Re uirement M M M M R M O R O M M Contents `6' Numeric TTTTAAAA Numeric Al hanumeric $$$$$$$$ Al hanumeric AI hanumeric Al hanumeric Numeric Numeric Len th 1 2 8 I 17 ]0 15 22 2 1 IS Position 01-01 02-03 04-11 12-12 13-29 30-39 40-54 55-76 77-78 74-79 80-94 "Taken from the WACHA (Wisconsin Automated Clearing House Association) Operating Rules, Appendix two, Subsection 2.1.16.) m Field 1, 4, 7, 90, & 77 Complete fields 1, 4, 7, 10, & 11 as required for file processing. F®eld 2: Transaction code The transaction code should be set to SAVINGS CREDIT. Field 3: Receiving DFl Identification HSA Bank's DFI or routing number is 075907947 Field 5: DFI Account Number The DFI Account Number is the individual's health savings account number. The account number can be obtained from the employees directly or you can make arrangements with HSA Bank to obtain the account numbers in coordination with your group's enrollment. Field 6: Amount The amount should only include the amount of the contribution from the specific source. ][f contributions are being made by both the employee and employer, you will need to include two separate entries with the specified amount for each. Field 8: Individual Name The individual name is the name of the employee/accountholder. Field 9: Discretionary Data This field is in the Entry Detail Record and allows financial institutions to include codes, of significance only to them, to enable specialized handling of the entry. There will be no standardized interpretation for the value of this field. The discretionary data field is used by HSA Bank to determine the type of contribution being made. The table to the right provides a list of codes for field 9 based on the type of contribution and year of contribution. Type Code for Field 9 Current Year Contribution Code for Field 9 Prior Year Contribution Em to er ER PR Employee Pre-tax throw h Cafeteria Plan EX PX Em to ee After-tax EE PE Deposit Account Agreement and Disclosures For Health Savings Accounts Effective Date: June 1, 2008 TABLE OF CONTENTS Deposit Account Agreement Page 1 Health Savings Account Custodial Agreement Page 5 Electronic Funds Transfer Agreement and Disclosures Page 6 How to Avoid Becoming a Victim of Identity Theft Page 9 We are pleased to provide you with this booklet that explains the terms and conditions of your Health Savings Account ("HSA"), Medical Savings Account("MSA"), Medicare Savings Account ("MCSA") or similar tax-advantaged healthcare-related accounts you may have with us. Unless identified otherwise, the term "Account" refers to any of the account types described above. Please read this booklet carefully and retain it for your records. Your Account is governed by the terms and conditions contained in this booklet; the laws of the United States; the laws of the state in which you opened your account as indicated in our records, including the Uniform Commercial Code ("UCC"); the rules and regulations of the Federal Reserve System, the Comptroller of the Currency, and the Federal Deposit Insurance Corporation; automated clearing house and local clearing house rules; and general banking practices in the area we serve. If a law is passed or regulation is promulgated that has the effect of making any provision contained in this booklet unenforceable or illegal, that provision will be invalid, but otherwise the terms and conditions in this booklet will remain in force. In this booklet, unless otherwise indicated, the words "you" or "your" mean the person who establishes the Account with us. The words "we", "us", "our", or "HSA Bank" mean HSA Bank®, a division of Webster Bank, N.A. A "business day" includes every day except Saturdays, Sundays, and federal holidays. DEPOSIT ACCOUNT AGREEMENT This Deposit Account Agreement (the "Agreement") contains general terms and conditions that apply to your Account. In addition, you have received an Interest and Fee Schedule, Privacy Policy and Disclosure, and other agreements and disclosures as applicable, which are considered to be part of your Agreement with us. This Agreement is updated and amended from time to time. This Agreement, as supplemented by the additional agreements and disclosures specifically referenced herein, is the complete and exclusive agreement between you and us related to your Account. If a conflict arises between the general and specific terms and conditions of this Agreement relative to a particular account, the specific terms and conditions will apply. If a conflict arises between this Agreement and the Health Savings Account Custodial Agreement, Electronic Fund Transfers Agreement and Disclosure included hereto, the Online Services Agreement, or any other agreement specifically referenced herein, such other agreement, as applicable, will apply. General Terms and Conditions I. Establishing Your Account Opening Your Account. By instructing us to open an Account, depositing funds in an Account, or having any interest in an Account, you agree to be bound by the terms and conditions of this Agreement. You agree that we may obtain reports from credit bureaus or consumer reporting agencies to investigate or reinvestigate any information that you provide. We also may verify your employment, pay, assets, debts, and references for purposes of considering your eligibility for products or services. Accurate Social Security Number, Name, and Address. You agree that any information you supply to us is complete and correct. You must certify the accuracy of your social security number on all forms where it is requested. If you do not accurately furnish your social security number or you are currently subject or become subject in the future to backup withholding, we can withhold amounts from your account as instructed by the Internal Revenue Service ("IRS"). You must inform us of all name and address changes to be assured that all appropriate statements and notices reach you. Whenever a statement is unclaimed or undeliverable because of your failure to provide adequate instructions or to notify us of a change in address, we may discontinue sending state- ments to you until otherwise instructed by you. Privacy, USA PATRIOT Act, and Opening an Account We respect and protect the confidentiality of customer information. We only request information that is necessary to open and service your account. Some of the information we request is required by a federal law called the USA PATRIOT Act and the regulations adopted by governmental agencies to implement it. This law requires us to obtain, verify, and record information that identifies each person or entity that opens an account. This information helps the government fight the funding of terrorism and money laundering activi- ties. When you open your Account, we will ask you for your name, street address, and date of birth. We also will ask you for an identification number, such as your social security number. This information allows us to identify you. In some instances, we also may ask to see your driver's license or other identifying documents. If your employer is facilitating your enrollment, you authorize your employer to provide us a copy of your IRS Form I-9 employment eligibility document. If your identity cannot be authenticated, or your application for your account is incomplete, your account may be opened in a frozen status. This means that we will restrict access to your account until we can verify your identity or we receive the necessary information to complete your application. Confidentiality. Information about your account and transactions in your account are confidential. We will not disclose such information to third parties except: (1) when it is necessary to complete transfers or to collect a check or other item; (2) in order to verify the existence and condition of your account for a third party, such as a credit bureau or payee, or in order to tell a third party who has one of your checks that we would be able to pay that check if that party presented it to us at that time for payment; (3} if you give us express permission, which we may require to have in writ- ing; (4) in order to comply with government agency regulations or court orders; (5} in order to collect money you owe us, or in connection with a claim by us or against us concerning a deposit or withdrawal from your account; (6) if we are presented with a legally enforceable instrument or court order, or in response to a proper governmental request under the USA PATRIOT Act; (7} if our officers, employees, or agents including accountants, auditors, service providers, attorneys, or collection agents, need information about your account or transactions in the course of their duties or as part of their review of our business affairs; (8) in order to collect information for our internal use, the use of our service providers, and our servicing agents and contractors about our electronic fund transfers services; or (g) where otherwise required or permitted under applicable law or our Privacy Policy and Disclosure. We work with several parties to provide acwunt services to you. These may include your employer, health insurance carrier, third party administrator for your employer or your health insur- ance carrier, multi-purse card, debit card, or other methods provided to you to pay for health care expenses using your Account, and data service providers. In order for those parties to provide transaction-related services to your account and information to you concerning your account, we will provide non-public personal information concerning your account to such parties, as appropri- ate to the type of Account program to which you belong and your services hereunder. Please rest assured that all customer information is kept in the strictest confidence, unless required by law to be disclosed. For additional information, please refer to your Privacy Policy and Disclosure. Ii. Depositing Money in Your Account Making a Deposft. You may deposit cash and noncash items into your Account by mail, wire transfer, or any other method we make available. To make a deposit by mail, you will need to use a deposit ticket or contribution form. You may obtain the contribution form by download from our website at www.hsabank.com or use the deposit tickets received with an order of checks for your Account. Checks must be deposited into the account of the party to whom the check is properly payable. We have the right to limit, refuse, or return any deposit. Please refer to the section of this Agreement entitled "Withdrawals" and to the sections of this Agreement following the heading "Funds Availability" for details concerning how and when we will make funds available to you, including when funds are considered to be deposited. Direct Deposit If you have arranged with a third party to have payments directly deposited into your Account, there may be special conditions concerning the deposited funds. If you have author- ized direct deposit into an account that is closed or otherwise unavailable to receive any deposit, we may elect, in our discretion, to return the deposit to the source. Claim Against Deposited Item. If a claim is made with respect to any item after final credit is given to your account with regard to the item on the grounds that the item was altered, had a forged or unauthorized signature or endorsement, or was not properly payable for some reason, we can withhold the amount of that item from your account until the claim is finally resolved. If we sustain any loss or damage as a result of relying on your representations or instructions regarding the item, you will be responsible for the costs and fees described in the section of this Agreement entitled "What Happens H You Owe Us Money or Cause Us to Sustain a Loss." Returned Items. If a check you deposit into your account or otherwise negotiate is found to have been drawn on an account with insufficient funds to pay it or is returned unpaid for any other rea- son, we may, in our discretion, do one of two things. First, we may deduct the amount of the returned item from your account, return the item to you, and charge a fee, if applicable. Second, we may redeposit it and charge a fee, if applicable. If we choose the latter option, you expressly agree that you have consented to this action and further agree that we have not waived or forfeited our right to chargeback your account 6y exercising the option to redeposit. Agent You authorize us to act as your agent with regard to the processing and collection of items to deposit or otherwise negotiate. We are not responsible for losses which happen during collec- tion of a check that are not caused by circumstances under our direct control. We will not be liable for the negligence of our correspondents or loss in transit of items deposited with us. You agree that we are legally entitled to supply any endorsement for you on any item you deposit or cash with us. If there is a qualified endorsement on any item, you agree that we may place your unquali- fied endorsement on the item. You are responsible for reconstruction and proof of loss of any items, including checks and other negotiable instruments, included in deposits that are lost or stolen in transit before we have received and accepted them. You also agree to cooperate fully and to assist in the reconstruction and proof of loss of any items, including checks and other negotiable instruments, included in deposits that are lost or stolen in transit after we have received and accepted them. Deposit Insurance. HSA Bank is a division of Webster Bank, N.A. and is not separately insured by the Federal Deposit Insurance Corporation. All deposits held by HSA Bank are combined with deposits held by Webster Bank, N.A. to determine the amount of deposit insurance that is available to depositors for all deposits they hold in a particular capacity. Deposits in HSA Bank are insured to the maximum amount permissible under federal law. Self-directed retirement accounts, such as IRA and Keogh accounts, held by Webster Bank, N.A. are separately insured. Any nondeposit investment product that you purchase using funds in your Account, including mutual funds, stocks, and bonds, is not FDIC-insured, is not a deposit or other obligation of HSA Bank or Webster Bank, N.A. and is not guaranteed by HSA Bank, Webster Bank, N.A. or any of their affiliates, is not insured by any federal government agency, and is subject to investment risk, including the possible loss of the principal amount invested. III. Withdrawing Money from Your Account Withdrawals. If you want to manually withdraw money from your account, you must fill out and sign a withdrawal form. You may obtain withdrawal forms by download from our website at www.hsabank.com or by telephone request. For your own protection, withdrawals from your account will not be allowed if we are not satisfied that the withdrawal is authorized. If all or any part of an item is uncollected funds or otherwise unavailable for withdrawal, your use of those funds is subject to our right not to permit a withdrawal until the funds are collected. Federal regulations give us the right to require you to give notice in writing not less than 7 days before you intend to withdraw all or a part of your Account. Longer notification periods may be enforced under certain circumstances. Withdrawals made from your Account using a check or your debit card will be reported to the IRS as normal distributions and should be made only for qualified medical expenses under the applicable federal law. To ensure accurate reporting to the IRS, a withdrawal form should be submitted to HSA Bank for any non-qualifying or non-medical transaction. When you submit a with- drawal form to us, we will send you a check that you may use for such a transaction. A fee will be charged for the withdrawal form as provided in your Interest and Fee Schedule. For withdrawals from your Account using a debit card, benefits card, or other device issued by a party other than HSA Bank, you should refer to your agreement for that card or device for additional rules of the issuer governing your withdrawals. Checks. When you open your account, you may order a supply of checks. The cost of the checks is listed in your Irrterest and Fee Schedule. Payment of Checks. We may pay items drawn on your account and presented on the same business day in any order determined by us, even if paying a particular item results in an insufficient balance in your account to pay one or more other items that otherwise could have been paid. We may change the order of payment at any time without notice to you. Preauthorized or Automatic Transfers. According to federal regulations, your account is limited to no more than 6 preauthorized or automatic transfers from your account during any monthly period. No more than 3 of those transfers may be made payable to third parties, such as point-of-sale ("POS") transactions, checks, or drafts. If you make more transfers during any month than you are allowed to make, you may be charged a fee and your privilege to make preauthorized or automatic transfers may be suspended or terminated, or your account may be closed. If a fee is to be charged, it will be listed in your Interest and Fee Schedule. You are not limited in the number of transfers you make through an ATM. Preauthor¢ed Drafts. You agree that, by giving your account number information to a creditor, you authorize the debits made to your account by that creditor. If there are duplicate or improper debits or other errors in the preauthorized drafts, you need to advise the creditor of the error and seek a recredit or other adjustment by the creditor. Transactions involving electronic fund transfers may be subject to other rules and regulations. Postdated item. We may charge against your account a check dated after the date it is presented (a postdated check), unless you give sufficient prior notice to us of the postdated check. This notice must provide certain information and be given to us in sufficient time for us to act according to the notice. Stale Checks. Under applicable law, we have no obligation to pay a check over 6 months old. We may choose, in our discretion and absent contrary instructions from you, to pay the check in good faith and charge your account or to return the check unpaid. Stop Payments. To stop payment on any item you have written on your checking account, you must notify us immediately. We will charge a fee as set forth in your Interest and Fee Schedule to process a stop payment order. The stop order must be received before the close of banking business the day before the item is presented for payment in order for us to have time to act on the stop order. We may request you io place the stop order in writing. The step order will remain in effect for 6 months and must be renewed in writing to stay in force. L ~ your verbal or written stop payment order, you must accurately describe the item by check number, precise dollar amount, the payee, and the number of the account on which the item was drawn. If the information you give us is not correct or complete, or if you do not give us other reasonable information requested about the check, we will not be responsible if we are not able to stop the payment of the item. Overdrafts. When a check or other item, including an electronic debit, is presented to us for payment, and there are not enough funds in your account to pay it, we will do one of two things. First, we may pay it. If the item is paid, then your account will be overdrawn. If your account becomes overdrawn, you will be notified promptly and told how much money you have to deposit to cover the overdraft. You agree to reimburse us for the amount of the overdraft and fee charged, if applicable, without delay. Second, we may return the item or refuse the debit without paying it. It is in our discretion whether to pay or to return the item. In either case, you will be charged an overdraft fee, which will be taken directly out of your account. The amount of the overdraft fee is listed in your Interest and Fee Schedule. Automated Clearing House ("ACH") Rules. All ACH credits and debits received for your account are subject to the rules of the National Automated Clearing House Association and any other applicable ACH rules. You agree to be bound by the ACH rules. Any credit that we give you for an ACH credit is provisional until we receive final payment. If we do not receive final payment, we may charge your Account for the amount or otherwise obtain a refund from you, and the party making payment to you will not be deemed to have paid you the amount of the entry. Except as reported in your periodic account statements, we will not notify you of the receipt of ACH transactions for your account. N. General Account Administration Interest Information. We may, in our discretion, change interest rates and annual percentage yields at any time unless stated otherwise in this Agreement. Such changes are generally based on economic conditions. We use the daily balance method to calculate the interest on your account. This method applies a daily periodic rate to the principal in your account each day. Interest begins to accrue on the business day you make your deposit. Interest is compounded and credited monthly. There is no minimum balance required to earn interest. We may not pay interest on funds deposited by a check that is returned unpaid. If you close your Account, interest that has accrued but has not yet posted will not be paid. Interest is compounded and credited monthly. There is no minimum balance required to earn interest. For additional information, please refer to your Interest and Fee Schedule. Statement of Accounts. A statement of your account will be sent at least quarterly to the most recent address for notices that we have for you in our records, which may be an email address if you have elected to receive statements electronically. If any statement is returned to us because of an incorrect address, we may stop sending statements to you. You agree to examine the state- ment carefully and reconcile the account. You also agree to carefully examine the items returned to you and to compare the items with the statement for problems, such as unauthorized signatures, alterations, or missing endorsements, and errors in the account balance that may indicate a bank error in crediting your account. You agree to contact us immediately about any error or problem with a statement or an item. This examination of your statement and items is called exercising "Reasonable Care." If you fail to exercise Reasonable Care in examining your statement or fail to report forgeries, alterations, or errors of any kind to us within 30 days of the mailing date of the earliest state- ment containing the item(s) in question, you waive any and all claims based on such problems. We use automated systems in the processing of checks in order to handle a high volume of items at the lowest cost to you. You agree that, to the extent that such systems are comparable to those used in general banking practice, their use constitutes ordinary care, and we will not be liable to you for forgeries, alterations, or other discrepancies not detected by such systems. We will not be liable for losses due to a forgery or an alteration that is of a nature that a bank could not be reason- ably expected to detect the fraud, or for forged or altered checks if the forgery or alteration arose from your negligence. Check Imaging. Check imaging is acomputer-generated image of the front of a check or draft. Your statement may include images of all the checks and drafts presented for payment during your statement cycle. You authorize us to retain and copy at our expense all checks and drafts drawn on your Account. At any time within 7 years after a check or draft is presented, you may obtain a copy of the item upon a written request that sufficiently identifies the requested item. A charge may be imposed for each copy. You agree that by retaining the original check or draft or a copy, we have made the item available to you in a reasonable manner. After a reasonable period of time as determined by us, the original items will be destroyed. If for any reason we cannot provide a copy of an item or satisfy your request by other means, we may be liable for no more than the face amount of the item or your actual damage, whichever is less. Abandoned Accounts. An Account may be considered inactive and abandoned when: 1) You fail to notify us in writing of any change to your mailing address, and after several attempts we are unable to verify an existing address, or 2) You have not made a deposit or withdrawal from your Account for one year or longer and after several attempts we are unable to verify you still intend to keep the Account. Accounts that are considered abandoned are subject to escheatment in accordance with the applicable law of your state of residence. We will attempt to contact you prior fo turning any deposit account over to the state. You agree that we are not responsible for any funds turned over to the state pursuant to applicable laws and regulations. If your funds are turned over to the state, you must apply to the applicable state agency to reclaim your funds. If your balance is zero or falls below zero for two consecutive months, HSA Bank reserves the right to close your account. Please refer to your Interest and Fee Schedule regarding fees that may apply. Right to Refuse Any Deposit, to Clase Any Account, or to Terminate Account Services. We reserve the right, in our discretion, to refuse to accept your deposit, including a new account deposit, to offer an account service, such as a debit card, or to close your account at any time. If we close your account and you owe us money for any reason, you will still be responsible for pay- ing the money due. Unless we determine that keeping your account open may present a risk to us, we will send notice of account closure to you effective 10 calendar days after the date of mailing to you. You agree that 10 calendar days is a reasonable time period for such notice. We reserve the right to prevent your access to your account or to close your account without notice when we reasonably believe we will otherwise sustain a loss. We also may prevent your use of your account without prior notice pending the resolution of a claim, investigation, or dispute concerning the account. Right To Discontinue Program. We reserve the right, in our discretion, to discontinue our Account program and related services without prior notice unless longer notice is required by law. Account Transfer. You may not transfer, assign, or pledge your Account without our prior written approval. We may transfer your account or assign or delegate any or all of our rights and respon- sibilities to any third party, without notice to you. What Happens if You Owe Us Money or Cause Us to Sustain a Loss. You agree to pay us for any costs incurred in collecting items you deposit or because you withdraw funds from your account in excess of your available account balance, for any items that are returned unpaid, or for any other transactions that result in a loss to us. These costs may include the cost of the item, related fees including research fees, and other fees. You also agree to pay interest at the rate of 12% or the statutory rate per annum, whichever is higher, for each day you have the use of funds that may not be fully collected. You also agree to pay our attorney fees and court costs in the event we hire an attorney to protect or assert against you any of our rights in this Agreement. Attorney fees, however, will not exceed the maximum fee allowable under applicable law. Limits of Liability. Unless expressly prohibited or othervvise restricted by applicable law or otherwise provided in this Agreement, our liability and the liability of our officers, directors, employees, or agents is limited as follows: We will not be liable to you for our performance of, or our failure to, perform any service under or in connection with this Agreement unless we have acted in bad faith or failed to exercise ordinary care. Without limiting the above, we will not be liable for delays or mistakes which happen because of reasons which are beyond our control, including, without limitation, acts of civil, mili- tary, or banking authorities, national emergencies, insurrection, war, riots, transportation failures, acts of God, including fires, floods, and other natural disasters, communication or power supply fail- ure, or malfunction of or unavoidable difficulties with our equipment, including computer malfunction or shutdown. If a court finds that we are liable to you because of what we did or did not do under or in connection with this Agreement, you may recover from us only your actual damages. In no event will you be able to recover from us consequential, punitive, or exemplary damages or lost profits, either in tort or contract, even if you advise us of the possibility of such damages, injury, or loss. Some jurisdictions do not allow the exclusion or limitation of implied warranties or liability for incidental or consequential damages, so the above exclusions or limitations may not apply to you. Legal Power of Attorney. Authorizing someone else to act in your place with respect to your account under a Legal Power of Attorney is acceptable, provided it is permitted by law and further pro- vided: (1) there is express language in the Power of Attomey, in proper legal form and in full force and effect, authorizing another person to act for you; (2) the nature of the authority granted is spe- cific as to banking transactions or otherwise authorizes access to your account; and (3) the Power of Attorney is either an original or a certified copy of the original document(s). Upon receiving an acceptable Power of Attorney, we may rely on it as valid and in force unless and until written notice of its revocation or termination is actually received by us. Under certain circumstances, addition- al information or documentation concerning the appointment, revocation, or termination of a Power of Attorney may be required. Authorized Signer. Authorizing someone else to act in your place with respect to your account as an Authorized Signer is acceptable, provided it is permitted by law and further provided that the authorized signer has been indicated on your application form or on a supplemental authorized signer form and you accept the terms provided on the form. Research Assistance and Processing Attachments, Levies, and Executions. A fee may be charged for researching or reconciling your accounts or other transactions and for assistance with your banking business. Unless otherwise prohibited pursuant to applicable law, a processing fee will be charged in connection with a levy, execution, or other pre-judgment or post-judgment process on your account by a creditor. Any applicable research and processing fees can be found in your Interest and Fee Schedule. If we incur any expense including, without limitation, reason- able attomey fees and costs of litigation, in responding to an attachment, garnishment, or other levy that is not otherwise reimbursed, we may charge such expenses against your account without prior notice to you. Changes to This Agreement vVe reserve the right to change this Agreement from time to time. Before imposing any new deposit account charge or increasing any current charge, we wiii give you notice before the effective date of the change. Unless we determine that failure to make such change may present a risk to us, we will send notice of any change to this Agreement effective 10 calendar days, unless longer notice is required by law, after the date of mailing to you. You agree that 10 calendar days is a reasonable time period for such notice. Any change or amendment to this Agreement, when it takes effect, will apply to all accounts and the funds in them even though the accounts were opened, or funds deposited, before the notice of the change was posted or the change took effect. If you do not agree to any change, you must notify us before the effective date of the change and terminate your account. Address far Notices. For purposes of this Agreement, notices to us should be mailed to HSA Bank, P.O. Box 939, Sheboygan, Wl 53082. Any notice to be given to you regarding your accounts will be considered effective when we mail it to the last address that we have for you in our records. Any notice to be given to us wilt be considered effective when we actually receive it and have had a reasonable time to act upon it. You must notify us of any change of your address as soon as possible. V. Substitute Checks Substitute Checks and Your Rights. This notice describes your rights in connection with a disputed transaction involving a substitute check received from us. The rights in this notice do not apply to original checks or to electronic debits to your account. However, you have rights under other law with respect to those transactions. What Is a Substitute Check? To make check processing faster, federal law permits banks to replace original checks with "substitute checks." These checks are similar in size to original checks with a slightly reduced image of the front and back of the original check. The front of a substitute check states: "This is a legal copy of your check. You can use it the same way you would use the original check." You may use a substitute check as proof of payment just like the original check. Some or all of the checks that you receive back from us may be substitute checks. What Are Your Rights Regarding Substitute Checks? In certain cases, federal law provides a special procedure that allows you to request a refund for losses you suffer if a substitute check is posted to your account (for example, if you think that we withdrew the wrong arnuunt from your account or that we withdrew money tram your account more than once for the same check). The losses you may attempt to recover under this procedure may include the amount that was withdrawn from your account and fees that were charged as a result of the withdrawal (for example, bounced check fees). The amount of your refund under this procedure is limited to the amount of your loss or the amount of the substitute check, whichever is Tess. You also are entitled to interest on the amount of your refund if your account is an interest-bearing account. If your loss exceeds the amount of the substitute check, you may be able to recover additional amounts under other law. If you use this procedure, you may receive up to $2,500 of your refund (plus interest if your account earns interest) within 10 business days after we receive your claim and the remainder of your refund (plus interest if your account earns interest) not later than 45 calendar days after we receive your claim. We may reverse the refund (including any interest on the refund) if we later demonstrate that the substitute check was correctly posted to your account. How Do I Make a Claim for a Refund? If you believe that you have suffered a loss relating to a substitute check that was posted to your account, please contact us at: HSA Bank, P.O. Box 939, Sheboygan, WI 53082 or 1-800-357-6246. You must contact us within 40 calendar days of the date that we mailed the substitute check in question or the account statement showing that the substitute check was posted to your account, whichever is later. We will extend this time period if you were not able to make a timely claim because of extraordinary circumstances. Your claim must include: ® A description of why you suffered a loss (for example, you think the amount withdrawn was incorrect}; v An estimate of the amount of your loss; • An explanation of why the substitute check you received is insufficient to confirm that you suffered a loss; • A copy of the substitute check and/or the following information to help us identify the substitute check: • Identifying information, for example, the check number; • Tire name of the person tc whom you wrote the check; • The amount of the check. VI. Wire Transfers If you use our wire transfer service and request nonrecurring fund transfers, the following terms and conditions will govern all transactions for our acceptance and processing of your fund transfers, payment orders, credits, and related requests. HSA Bank will not initiate or receive wire transfer requests for you unless you have an open account relationship with us. Repetitive funds transfers to an Account are not permitted. Wire transfers wiff be governed by the laws of the state in which you opened your account as indicated in cur records, including Article 4A of the UCC. Unless other- wise defined, the terms used herein will have the same meaning as defined in Article 4A of the UCC. Notwithstanding the foregoing, to the extent that Federal Reserve Regulation J governs some aspects of FedFunds transfers and New York Clearing House Interbank Payment Systems ("CHIPS") rules govern some aspects of CHIPS transfers, those respective rules will control. Authorization and Security Procedure. We have established rules and security procedures for you to initiate and receive funds transfers from your Account. You must confirm your identity in a manner acceptable to HSA Bank to place a payment order. You agree that this security procedure is commercially reasonable in view of the type, value, and frequency of the payment orders you request. We may, in our discretion, adopt additional security procedures. You are responsible for the accuracy of the information in the payment order and for the completion of the form, and we are entitled to rely upon the content thereof. Instructions or Changes. By complying with our authorization and security procedure, you authorize and direct us to debit your account and transfer the funds. We may handle payment orders received from you and other customers in any order selected by us, unless otherwise instructed by you. The transfer of funds may be effected through any one, or a series of, correspondent banks of the beneficiary's bank in a manner deemed most appropriate and effective by us or by any other bank participating in the funds transfer. If you as the originator of the payment order require us to use a specific intermediary bank and the intermediary bank fails, you agree that you will nonetheless be obliged to pay your payment order and we will have no liability for any loss resulting from the failure of the intermediary bank. We will have the maximum protection afforded under applicable law in the event of a failure of a bank that is a party to a funds transfer. Canceling or Amending an Order. We are not obligated to attempt to cancel or amend a payment order. If we elect to attempt to cancel or amend an order, the rules below apply. By requesting cancellation or amendment of a payment order, you realize that you may be liable under the UCC and agree that you accept such liability. Any communication seeking to cancel or amend a payment order will not be effective to cancel or amend the order unless (1) the communication is in writing and presented in the same manner in which the payment order was placed, and (2) either (a) HSA Bank and all other receiving banks, including the beneficiary's bank, have a reasonable amount of time to respond before the order has been accepted, or (b) HSA Bank and all such other banks agree to the cancellation or amendment and such amendment or cancellation is allowed by law. Complete Discretion to Accept or Reject Orders. We may, in our discretion and without liability of any kind to you, accept or reject any payment order requested. We will make reasonable attempts to provide you with a notice of rejection by telephone on the same funds transfer business day as the request for the payment order is received. If we receive a payment order from a third party for which you are the intended beneficiary, we have no obligation to accept the payment order, unless we have agreed with you to accept the order or we are bound by a funds transfer sys- tem rule or by law to do so. Cutoff Time. We will make reasonable efforts to execute orders on the same funds transfer business day. An order must be received by us before the applicable cutoff time on that funds transfer business day in order to make a "same day transfer" possible. We do not guarantee the funds transfer transaction will be completed on the same funds transfer business day. For domestic funds transfers our "funds transfer business day" is that part of a business day prior to 2:00 p.m., Central, Monday through Friday, that we are open for processing and transmittal of wire transfer pay- ment orders and other communications relating to payment orders. International funds transfers are not available. Identifying Numbers Supersede Identified Names. If there is any inconsistency in a payment order between an identifying number and a name given in the payment order, we may use the iden- tifying number in executing the payment order without verifying that the number is correct. You expressly acknowledge that when a payment order identifies a beneficiary, beneficiary's bank, or intermediary bank inconsistently by name and an identifying number, payment may be made by the intermediary or beneficiary bank on the basis of the identifying number, even if the identifying number identifies a person or entity different from the named beneficiary in your payment order. Your obligation to pay the payment order shall not be excused by your error. HSA Bank and other banks accepting the orders are not required to check or verify any identifying or account number given 6y you with any name given. You agree, therefore, that HSA Bank and others may rely on identifying or account numbers that you provide to us. Notification of Discrepancy and Refunds. You agree to examine your receipt, statement, or passbook, as applicable, and give us prompt notice of any error or discrepancy. Unless prohibited by applicable law, in the event that the beneficiary does not receive payment of the transfer and you are entitled to a refund, we will refund the amount to you upon our receipt of the returned funds, less any expenses associated with the recovery. We will notify you of a refund as soon as reasonably practical. Liability. This provision is in addition to the section included in mart iV of this Agreement entitled "Limits of Liability." We will exercise reasonable care in providing the services hereunder, but in no event will we be liable for any consequential, exemplary, or indirect damages or lost profits except where required by law. We will not be liable for any error, delay, or default on our part or any third party used by us in the execution of any transfer or related act, except to the extent such liability is required by law and cannot legally be varied or waived by agreement. In no event will attorney fees be recoverable without first making demand for, and then being refused, recovery. In no event will we be liable for any consequential, exemplary, or indirect damages or lost profits except where required by law. You agree that you have waived our liability to the maximum extent allowed by law. We will not be responsible for your acts or omissions (including, without limitation, the amount, accuracy, timeliness of transmittal, or due authorization of any payment order received from you) or those of any other person, beneficiary, or intermediary or beneficiary's bank (including, without limitation, the return or rejection of a payment order by such beneficiary's bank), and no such person will be deemed to be our agent. Without limiting the generality of the foregoing provisions, we shall be excused from failing to act or delay in acting if such failure or delay is caused by legal constraint, interruption of transmission or communication facilities, equipment failure, emergency conditions or other circumstances beyond our control. You agree to indemnify us against any loss, liability, or expenses (including attorneys' fees and expenses) resulting from or arising out of any claim of any person that we are responsible for any act or omission other than those acts and omissions for which we are responsible as provided in this section. Interest. You agree that in the event we become liable to you for the payment of interest as the result of a complete or incomplete funds transfer, interest will be paid at the lowest rate of interest then being paid on deposits by us. Amendment. We may amend this agreement at any time. An amendment will not affect the rights or liabilities of either parry created prior to the amendment. VII. Funds Availability Our policy regarding funds availability is designed to make funds available as soon as possible and to protect our customers' deposits. When a deposit is received; the availability of funds may be delayed consistent with funds availability laws. During this period, we will not use the funds to pay checks that you have written. If you need immediate availability from a deposit, please ask us when the funds will be available for withdrawal. Not all checks will clear during the applicable check hold period. You are responsible for returned items that have been credited to and withdrawn from your account. Determining the Availability of a Deposit. The length of the delay is counted in business days from the day of your deposit. Every day is a business day except Saturdays, Sundays, and federal holidays. Same Day Availability. Funds from the following deposits are available on the day of your deposit: • Cash. • Wire transfers. • Electronic direct deposits and transfers. • Checks drawn on U.S. banks. Checks drawn on foreign banks will be handled on a collection basis and will be available when we receive payment. Funds You Deposit by Check May Be Delayed for a Longer Period under the Following Circumstances. 1. We believe a check you deposit will not be paid. 2. You deposit checks totaling more than $5,000 on any one day. 3. You redeposit a check that has been returned unpaid. 4. You have overdrawn your account repeatedly in the last 6 months. 5. There is an emergency, such as failure of communications or computer equipment. We will notify you in writing if your ability to withdraw funds is delayed for any of these reasons, and we will tell you when the funds will be available. Funds will generally be available no later than 5 additional days beyond the normal availability schedule. If You Are a New Customer, the Following Special Rules May Apply During the First 30 Calendar Days Your Account Is Open. We may, in our discretion, limit the next day availability of funds to the first $5,000 of funds deposited via check on any business day. All other funds that you deposit will be available on the fifth business day. Automated Teller Machine Deposits. Deposits to HSA Bank may not be made by deposit at an ATM. HEALTH SAVINGS ACCOUNT CUSTODIAL AGREEMENT This Custodial Agreement applies to all persons establishing an HSA under Section 223(a) of the Internal Revenue Code ("Code"} exclusively for the purpose of paying or reimbursing qualified medical expenses of the person and his or her spouse and dependents. This Health Savings Account Custodial Agreement does not apply to any other type of Account. A separate custodial agreement will be provided for other Accounts as applicable. By submitting an application for your HSA, you appoint us, and we, by accepting the application and accepting delivery of account items for your HSA, agree to serve as custodian of your HSA pursuant to the terms of this Custodial Agreement. Eligibility. You have assigned to the HSA established pursuant to this Custodial Agreement the sum indicated on your application ("Application"). Unless the HSA is used solely to make rollover contributions, you represent that you are eligible to contribute to the HSA; specifically, you represent that you: (1) are (or as of the effective date set forth in the Application will be) covered under a high deductible health plan ("HDHP"); (2) are not also covered by any other health plan that is not an HDHP (with certain exceptions for plans providing preventative care and limited types of per- mitted insurance and permitted coverage); (3) are not enrolled in Medicare; and (4) cannot be claimed as a dependent on another person's tax return. It is your responsibility to determine your eli- gibility to make contribution to your HSA. Contributions. We may accept additional cash contributions for the tax year that are made by you or on your behalf (by an employer, family member, or any other person). You will be responsi- ble for any tax consequences that exceed the Contribution Limits set annually by the Internal Revenue Service for single or fatuity coverage. Contributions for any tax year may be made at any time before the deadline for filing your federal income tax return for that year (without extensions). Rollover contributions from an HSA, an Archer Medical Savings Account ("Archer MSA"), Flexible Spending Arrangement ("FSA"), Health Reimbursement Arrangement ("HRA"), need not be in cash and are not subject to the maximum annual contribution limit set forth under "Contribution Limits." Transfers from an Individual Retirement Account ("IRA") need not be in cash but are subject to the maximum annual contribution limit. Additional limitations, restrictions, and conditions apply. Please consult your tax consultant prior to initiating any transfer or roll over of funds. Contribution Limits. You can make wntributions up to the maximum annual contribution limit as defined in the Code. Contribution limits are subject to acost-of-living adjustment each year. To view the current limits, please visit our website at www.hsabank.com or the IRS at www.irs.gov. For tax years 2007 and later, contributions do not need to be prorated as long as you maintain HSA coverage for the appropriate testing period as outlined in the Health Opportunity Patient Empowerment Act of 2006. Contributions to Archer MSAs, other HSAs, and transfers from an IRA count toward the maximum annual contribution limit to this HSA. For calendar year 2008, if you are age 55 or older and not enrolled in Medicare, an additional $900 catch-up contribution may be made by you or on your behalf. The catch-up contribution increases $1,000 in 2009 and later years. Contributions in excess of the maximum annual contribution limit (other than catch-up or rollover con- tributions) are subject to an additional tax penalty in addition to bank fees incurred to remove such excess contributions. Excess Contributions. It is your responsibility to determine the limit under the Code for each tax year for all contributions to your HSA and whether contributions to your HSA exceed the maximum annual contribution limit (and catch-up contribution limit, if you are eligible). If contributions to your HSA exceed the applicable maximum annual contribution limit, it is your responsibility to request the withdrawal of the excess contributions and any net income attributable to such excess contributions. Claims Against Your HSA. Your interest in your HSA is non-forfeitable. Prohibfted Transactions. No part of the custodial funds may be invested in life insurance contracts or in collectibles as defined in Code Section 408(m). The assets of your HSA may not be com- mingled with other property except in a common trust fund or common investment fund. Neither you nor we will engage in any prohibited transaction with respect to your HSA (such as borrowing or pledging the account or engaging in any other prohibited transaction as defined in Code Section 4975). Distributions. Distributions of funds from your HSA may be made upon your direction. Distributions from your HSA that are used exclusively to pay or reimburse qualified medical expenses for you, your spouse, or dependents are tax-free. Distributions must occur after the establishment date of the account in order to qualify as a tax-free distribution. Please consult a tax advisor regard- ing the tax treatment of any distributions from your Account. Distributions that are not used for qualified medical expenses are included in your gross income and are subject to an additional 10 per- centtax on those distributions. The additional 10 percent tax does not apply if the distribution is made after your death, disability, or reaching age 65. We are not required to determine whether the distribution is for the payment or reimbursement of qualified medical expenses. You alone are responsible for substantiating that the distribution is for qualified medical expenses and you must maintain records sufficient to show, if required to do so, that the distribution is tax-free. Successor in Interest. If you die before the entire interest in your HSA is distributed, the entire remaining interest will be disposed of as follows: • If your spouse is the beneficiary, your HSA will become your spouse's HSA as of the date of your death. • If your spouse is not the beneficiary or you have no spouse, your HSA will cease to be an HSA account as of the date of your death. If your estate is the beneficiary, the fair market value of your HSA as of the date of your death is taxable on your final tax return. For other beneficiaries, the fair market value of your HSA is taxable to that person in the tax year that includes the date of your death. Preparation of Reports. You agree to provide us with information necessary for us to prepare any report or return required by the IRS. We agree to submit any report or return as prescribed by the IRS. Integration with Other Provisions. Notwithstanding any other section that may be added or incorporated in this Custodial Agreement, the preceding sections of this Custodial Agreement and this sentence are controlling. Any section in this Custodial Agreement chat is inconsistent with Code Section 223 or iRS published guidance will be void. Amendments. This Custodial Agreement will be amended from time to time to comply with the provisions of the Code or IRS published guidance. Other amendments may be made with the mutual consent of you and us. Genera{ Provisions. The following general terms apply: • Notices and Changes of Address. All notices to us should be mailed to HSA Bank, P.O. Box 939, Sheboygan, WI 53082. Any notice to be given to you regarding your accounts will be considered effective when we mail it to the last address that we have for you in our records. Any notice to be given to us will be considered effective when we actually receive it and have had a reasonable time to act upon it. You must notify us of any change of your address as soon as possible. ® Representations and Responsibilities. You represent and warrant to us that any information you have given or will give us with respect to this Custodial Agreement is complete and accu- rate. Further, you agree that any directions you give us, or any action you take will be proper under this Custodial Agreement and that we are entitled to rely upon any such information or directions. We shall not be responsible for losses of any kind that may result from your directions to us or your actions or failures to act, and you agree to reimburse us for any losses we may incur as a result of such directions, actions or failures to act. We shall not be responsible for any penalties, taxes, judgments, or expenses you incur in connection with your HSA. We have no duty to determine whether your contributions or distributions comply with the Code, regulations, rulings, or this Custodial Agreement. • Service Fees. We have the right to charge an annual service fee or other designated fees (for example, a transfer, withdrawal, or termination fee) for maintaining your HSA. In addition, we have the right to be reimbursed for all reasonable expenses we incur in connection with the administration of your HSA. We may charge you separately for any fees or expenses, or we may deduct the amount of the fees or expenses from the assets in your HSA, at our discretion. We reserve the right to charge any additional fee, upon 30 days notice to you that the fee will be effective. Any brokerage commissions attributable to the assets in your HSA will be charged to your HSA. You cannot reimburse your HSA for those commissions. ® Investment of Amounts in Your HSA. You will select the type of investment for your HSA assets; provided, however, that your selection of investments will be limited to those types of investments that we are authorized by our charter to offer and do in fact offer for investment in HSAs. Any investment that you select for your HSA will be subject to any and all restrictions or limitations, direct or indirect, that are imposed by or flow from our articles or bylaws and all federal and state laws and regulations that apply to us. ® Account Management. To the extent not prohibited by law, you authorize us to liquidate and transfer the cash proceeds of any investment you have selected for your HSA in the event that a negative cash balance exists in your HSA for more than 10 business days. We will notify you of the negative cash balance to give you the opportunity to make additional contributions, if allowable, or sell the investments of your choice to resolve the negative cash balance. If the negative balance is not corrected within a reasonable time after we notify you, we will liquidate any of your HSA investments, at our discretion, to the extent necessary to bring your balance to a positive amount. In the event that liquidating all of your HSA investments is not sufficient to resolve the negative balance, you will be responsible for any remaining deficiency. • Beneficiaries. You may designate one or more persons or entities as the beneficiary(ies} of your HSA. This designation can only be made on a form prescribed by us and will only be effec- tive when filed with us during your lifetime. Unless specified otherwise in writing by you, each beneficiary designation you file with us will cancel all previous designations. The consent of a beneficiary will not be required for you to revoke a beneficiary designation. If you do not designate a beneficiary, your estate will be the beneficiary. • Termination. Either you or we may terminate this Custodial Agreement at any time by giving written notice to the other party. We can resign as custodian at any time effective 30 days after we mail written notice of our resignation to you. Upon receipt of that notice, you must make arrangements to transfer your HSA to another financial organization. If you do not complete a transfer of your HSA within 30 days from the date we mail the notice to you, we have the right to transfer your HSA assets to a successor HSA custodian or trustee that we choose in our sole discretion, or we may pay your HSA to you in a single sum. We shall not be liable for any actions or failures to act on the part of any successor custodian or trustee, nor for any tax con- sequencesyou may incur that result from the transfer or distribution of your assets pursuant to this Section. If this Agreement is terminated, we may hold back from your HSA a reasonable amount that we believe is necessary to cover any one or more of the following: • Any fees, expenses or taxes chargeable against your HSA. • Any penalties associated with the early withdrawal of any savings instrument or other investments in your HSA. If we merge with another organization (or come under the control of any federal or state agency} or if our entire organization (or any portion which includes your HSA) is bought by another organization, that organization (or agency) shall automatically become the trustee or custodian of your HSA, but only if that organization is the type of organization authorized to serve as an HSA trustee or custodian. If we fail to comply with certain Treasury regulations, or we are not keeping the records, making the returns, or sending the statements that are required by forms or regulations, the IRS may, after notifying you, require you to substitute another custodian or trustee. Amendments. We have the right to amend this Custodial Agreement at any time. Any amendment we make to comply with the Code and related regulations does not require your consent. You will be deemed to have consented to any other amendments unless, within 30 days from the date we mail the amendment, you notify us in writing that you do not consent. Withdrawals. All requests for withdrawal must be in writing on a form provided by or acceptable to us. The method of distribution must be specified in writing. The tax identification number of the recipient must be provided to us before we are obligated to make a distribution. Any withdrawals will be subject to all applicable tax and other Taws and regulations, including possible early withdrawal penalties and withholding requirements. We reserve the right to reasonably restrict the frequency and/or minimum amount of distributions. Transfer from Other Plans. We can receive amounts transferred to your HSA from the custodian or trustee of another HSA or Medical Savings Account. However, we also reserve the right not to accept any transfer. Liquidation of Assets. We have the right to liquidate assets in your HSA if necessary to make distributions or to pay fees, expenses, or taxes properly chargeable against your HSA. If you fail to direct us to which assets to liquidate, we will decide in our complete and sole discretion, and you agree not to hold us liable for any adverse consequences that result from our deci- sion. Restrictions on the Fund. Neither you nor any beneficiary may sell, transfer, or pledge any interest in your HSA in any manner whatsoever, except as provided by law or this Custodial Agreement. The assets in your HSA will not be responsible for the debts, contracts, or torts of any person entitled to distributions under this Custodial Agreement. What Law Applies. This Custodial Agreement is subject to all applicable federal and state laws and regulations. If it is necessary to apply any state law to interpret and administer this Custodial Agreement, the law of the State of Connecticut will govern. If any part of this Custodial Agreement is held to be illegal or invalid, the remaining parts will not be affected. Neither your nor our failure to enforce at any time or for any period of time any of the provisions of this Custodial Agreement will be construed as a waiver either of such provisions or of your or our right thereafter to enforce each and every such provision. • Identifying Number. Your social security number will serve as the identification number of your HSA. If you are married and your spouse is eligible to open an HSA and wants to contribute to an HSA, he or she must establish his or her own account. An employer identification number is required only for an HSA for which a return is filed to report unrelated business taxable income. An employer identification number is required for a common fund created for HSAs. Limitations of Liabiliiy. We will not be liable to you for any losses, damages, costs, penalties, or expenses you may incur as a result of your employer's failure to make any employer contri- butions to your HSA. We are not responsible for monitoring or notifying you of your employer's contributions to your HSA. You are responsible for contacting your employer regarding its con- tributions and monitoring those contributions. We will provide statements to you on at least a quarterly basis. We will not be liable to you for any statements, representations, actions, or inactions of any insurance agent or agency that sells you an insurance plan in connection with your HSA. The insurance agent or agency is not our partner, agent, affiliate, representative, or co-venturer. ELECTRONIC FUND TRANSFERS AfSREEMENT AND DISCLOSURE I. General Teams and Conditions This EFT Agreement explains your rights, liabilities, and responsibilities for electronic fund transfers related to your accounts. For electronic fund transfers that you direct through the Internet, the Online Agreement also is applicable. For withdrawals from your Account using a debit card, benefits card, or other device issued by a party other than HSA Bank, you should refer to your agree- mentfor that card or device for additional rules of the issuer governing your withdrawals. Electronic Banking Services Available. The following services are available subject to application or approval: Telephone Banking. • Automatic And Preauthorized Transfers. You may make automatic and preauthorized transfers to and from your account. + Electronic Check Conversion. You may authorize your personal check to be used as a source of information for the check number, your checking account number, and the number that identifies us. This information is then used by the merchant or payee to make cone-time electronic payment from your account, an electronic fund transfer. ACH Transfers. You may authorize a transfer over the Internet or by telephone through the ACH network by providing a third party with your account number and the number that identifies us. Debit Card. You may use your debit card and your personal identification number ("PIN") to withdraw cash from an ATM and to debit your account in connection with POS transactions. You may use your debit card to make purchases at any merchant location that displays the VISAx logo. When you use your debit card to make purchases, you are requesting us to withdraw funds from your checking account to pay for the purchases. Limits on Electronic Banking Services. In addition to any conditions listed above, the following transactions are subject to the conditions described: • Debit Card Limits. You may use your debit card to withdraw up to a total of $300 from your account on any one calendar day at ATMs and POS terminals. You may request us to reduce your daily withdrawal limit to as little as $50 per debit card, or you may request us, subject to our approval, to increase your daily withdrawal limit. Your debit card may not be used for any illegal transaction. Debk Card Purchases. A debit card is issued exclusively for use with your Account. You may use your debit card to make purchases at any merchant location that displays the VISA logo in an amount of up to $2,000 on any one calendar day. When your debit card is used for a purchase through an EFT network, we may place a hold on the funds available in your account that maybe necessary to cover the transaction. The hold will be in the amount of the transaction request that has been submitted by the merchant for authorization. Held funds will not be avail- able for withdrawal or check writing purposes during the period the hold is in effect. The hold will be in effect for no more than 3 business days. You are responsible for resolving with a mer- chant that accepts the card all disputes concerning the quality of goods and services purchased. International Transactions Exchange Rate. The exchange rate between the transaction currency and the billing currency used for processing international transactions is a rate selected by an EFT network from the range of rates available in wholesale currency markets for the applicable central processing date, which rate may vary from the rate the EFT network receives, or the government-mandated rate in effect for the applicable central processing date, in each instance, plus or minus any adjustment determined by the issuer. ATM Networks. You can use your debit card with your PIN at certain regional, national, and international ATM networks. Those network logos appear on the back of your debit card. The amount, dollar denominations, and daily limit you may transfer each time you use your debit card at ATMs depends on the network agreement and prevailing law governing the shared use of other ierminals and limitations of the ATM or terminal you are using. A fee may be imposed far electronic fund transfers initiated at an ATM operated by an entity other than Webster Bank, N.A. Other Limits. We own the debit card issued by us to you for use with your Account. If we ask for the debit card, you must give it back to us. We also reserve the right to refuse to offer you a debit card, or to terminate the debit card without notice. If there are not enough funds in your account when a debit card transaction is performed, we may, in our discretion, do one of two things. First, the transaction may be paid. If it is paid and your account is overdrawn, you will be notified promptly and told how much money you have to deposit to cover the overdraft. You agree to promptly reimburse us any overdrawn amount and pay applicable fees; the fees are listed in your Interest and Fee Schedule. Just because we honor an overdraft on a particular transaction does not mean we will do so in the future. We may also refuse to pay the transaction. • Termination of Service. We reserve the right to terminate without notice any of the described electronic fund transfer services. Termination will not affect any of our rights or your obligations arising under this EFT Agreement prior to termination, or any rights and liabilities hereunder arising out of completed transactions, whether such transactions occur before or after termination. If we terminate, you agree to surrender your card(s) immediately. We also reserve the right to renew all cards at our discretion. ® Fees. There may be a fee for certain services. Please see your Interest and Fee Schedule. Additionally, when you use an ATM not owned by Webster Bank, N.A., you may be charged a fee by the ATM operator. SERVICES GOVERNED BY SPECIAL RULES NOT INCLUDED IN THIS AGREEMENT Online Services. Online Services has a separate agreement that governs its use. To the extent that there is a conflict between the Online Services Agreement and the Electronic Funds Transfer Agreement, the Online Services Agreement will control. 11. Liability Your Liability. You agree to protect your debit card and PIN and to sign the signature panel on the back of your card immediately upon receiving it. Do not keep your debit card and PIN in the same place. You agree to memorize your PIN and destroy any paper on which it is written. Do not give your debit card or PIN to anyone. Do not let anyone see you enter your PIN. If someone uses your debit card or its number without your consent, you agree to give us a written sworn statement detailing the wrongful use and help us in investigating the circumstances. The statement will be in the form prescribed by us and completed by you. We do not have to credit you for your losses before you give us the required statement. You agree to look at your statements as soon as you receive them. If a statement shows a transfer not made by you, you will tell us promptly. If you do not tell us within 60 days after we mail the statement to you, the statement will be deemed to be correct, and you will not be able to challenge any errors. Receipts. Always take your ATM receipt(s) before leaving an ATM. Keep the merchant receipt(s) and destroy carbon copies and receipts to safeguard your account number. Unauthorized Transfers. You must tell us AT ONCE if you believe your Visa debit card and/or your PIN has been lost or stolen or obtained without your permission, or if you believe that an elec- tronic fund transfer has been made without your permission using information from your check. Notifying us by telephone immediately is the best way of limiting your possible losses. You could lose all of the money in your account. If you believe your Visa debit card or your PIN has been lost or stolen and you tell us within two (2) business days after you learn of the loss or theft, you can lose no more than $50 if someone used your card or your PIN without your permission. If you do NOT tell us within two business days after you learn of the Toss or theft, and we can prove we could have stopped someone from using your card or your PIN without your permission if you had told us, you could lose as much as $500. Your liability will not exceed the lesser of $500 or the sum of (1) $50 or the amount of unauthorized transactions that occur within the two business days, whichever is less; and (2) the amount of unauthorized transactions that occur after the close of two business days and before such notice to HSA Bank, provided HSA Bank establishes that the transfers would not have occurred had you notified HSA Bank within the two day period. Also, if your statement shows electronic transactions or transfers that you did not make, including those made with your Visa debit card, PIN, or other means, tell us AT ONCE. If you do not tell us within sixty (60) days after the statement was mailed to you, your liability will not exceed the amount of the unauthorized transactions that occur after the close of the 60 days and before notice to NSA Bank. 5'ou may not get back any money you Icst after the 60 days if we car. prove that we could have stopped someone from taking the money if you had told us in time. If a good reason (such as a long trip or a hospital stay) kept you from telling us, we will extend the time periods for a reasonable period of time. If you believe your Visa debit card or your PIN has been lost or stolen or that someone has transferred or may transfer money from your account without your permission, notify us immediately by telephoning or writing us. Unless you have been grossly negli- gent or have engaged in fraud, you are eligible for additional limits on liability for Visa card transactions routed via the Visa network. An example of a transaction routed via the Visa Network is a Visa debit card merchant purchase that requires your signature rather than your PIN to complete. Online or telephone purchases when you are providing your Visa Debit Card number as the method of purchasing are also examples of transactions routed via the Visa network. These transactions are eligible for the Visa zero liability policy. The policy provides Visa debit cardholders with full protection against unauthorized transactions processed through the Visa network. This additional limit on liability does not apply to ATM transactions or to transactions using your PIN, which are not processed by Visa. If your Visa debit card is lost or stolen, or you discover an unauthorized transaction on your statement, you agree to immediately notify us. You also agree to assist us in our attempts to recover any losses from unauthorized users and to assist in their prosecution. Please contact us at our address and telephone number listed belour. Debit Card & Other Electronic Services 800-357-6246 (Business hours) NSA Bank, P.O. Box 939, Sheboygan, WI 53082-0939 Debit Card After Hours 800-523.4175 Liability. tf we do not complete a transfer to or from your account on time or in the correct amount according to our agreement with you, we will be liable for your losses or damages. However, there are some exceptions. For example, we will not be liable in the following circumstances: • Through no fault of ours, you do not have enough available funds in your account to make the transfer, or you have closed the designated account. ® The funds required to cover the transaction are subject to a hold, dispute, lien, legal process, or other encumbrance restricting the transfer. • The ATM where you are making the transaction does not have enough cash. • The ATM or system, the POS terminal or system, or other electronic system was not working properly and you knew of, or had reason to question the possibility of, the malfunction while you attempted to make the transfer. • We have identified you as a credit risk and have chosen to close your account. • We are otherwise exempted from liability under applicable laws and regulations. There also may be other exceptions. Error Resolution Notice. In case of errors or questions about your electronic transfers or your statements or receipts, telephone us or write us as soon as you can. Our address and telephone number are listed previously. We must hear from you no later than 60 days after we send the FIRST statement on which the problem or error appeared. • Tell us your name and account number. • Describe the error or the transfer you are unsure about, and explain as clearly as you can why you believe it is an error or why you need more information. • Tell us the dollar amount of the suspected error. If you tell us orally, we will require that you send us your complaint or question in writing within 10 business days. Generally, we will tell you the results of our investigation within 10 business days after we receive the confirmation from you and will correct any error promptly. If we need more time, however, we may take up to 45 calendar days to investigate your complaint or question. If we decide to do this, we will recredit your account within 10 business days for the amount you think is in error, so that you will have the use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing, and we do not receive your complaint or question in writing within 10 business days, we may choose not to credit your account. For POS transactions and for transactions that were initiated in a foreign country, the investigation period is extended to 90 calendar days. If you are a new customer to NSA Bank and you place a claim during the first 30 calendar days your account is open, the investigation period is 90 calendar days and the time period to recredit your account may be extended to 20 business days. We will send you a written explanation of our determination within 3 business days after we finish our investigation. You may ask for copies of the documents we used in our investigation. If we have provisionally recredited your account during the investigation and determine that there was no error, you will be required to return any credit of funds you have received from us. If you do not return the funds, and subject to certain restrictions, we have the right to take the funds out of your account. tfl. Other Information Right to Receive Documentation of Transfers. You will get an account statement on at least a quarterly basis. If you have arranged to have direct deposits made to your account at least once every 60 days ftom the same person or company, you can call us to find out whether or not the deposit has been made. Stop Payments and Notice of Varying Amounts. Unless otherwise provided in this EFT Agreement, you understand that you cannot stop an electronic fund transfer other than a preauthorized payment. If you teli us in advance to make regular payments out of your account, you can stop any of those payments. Call us or write us in time for us to receive your request 3 business days or more before the payment or transfer is scheduled to be made. If you call, we will also require you to put your request in writing and deliver the written confirmation to us within 14 calendar days after you call. There is a fee to place a stop payment on a preauthorized payment. Please refer to your Interest and Fee Schedule. When a preauthorized electronic fund transfer from your account will vary in amount from the previous transfer under the same authorization or from the preauthorized amount, the designat• ed payee is required to send you written notice of the amount and the date of the transfer at least 10 calendar days before the scheduled date of transfer. If you order us to stop one of these payments 3 business days or more before the transfer is scheduled, and we do not do so, we may be liable for your losses or damages. When You Owe Us Money. If you owe us money for fees or because an unauthorized transfer or an error that you reported is not supported by our investigation, you agree to pay us the amount of the provisional credit. You also may be responsible for costs we incur, including attorney fees, to collect the debt you owe. For Your Safety When Using an ATM, Please Observe the Following: Choose swell-lighted ATM and park close to it. Have someone come with you when using an ATM at night. If the ATM you are using is inside a building, close the entry door completely upon entering. When using adrive-up ATM, keep your engine running, lock your doors, and roll up all the windows, with the exception of the driver's window. Be aware of your surroundings. If you believe you are being watched or followed, cancel your transaction, then go to swell-populated area. If necessary, call the police. Do not write your PIN on or near your debit card. Do not give your PIN or your debit card to anyone. + Have your debit card and any paperwork ready before you get to the ATM. This will save you time, and allow you to pay more attention to your surroundings. Place withdrawn cash out of sight in a secure place before stepping away from an ATM. HOW TO AVOID BECOMING A VICTIM OF IDENTITY THEFT Identity Theft Identity theft is the fraudulent use of a person`s personal identifying information. Often, identity thieves will use another person's personal information, such as a social security num- ber, mother's maiden name, date of birth, or account number, to open fraudulent new credit card accounts, charge existing credit card accounts, open bank accounts, write checks, or obtain new loans. Thieves may obtain this information by: • Stealing wallets that contain personal identification information and credit cards. • Stealing bank statements from the mail. • Diverting mail from its intended recipients by submitting a change of address form. • Rummaging through trash for personal data. • Stealing personal identification information from workplace records. • Intercepting or otherwise obtaining information transmitted electronically. Pretext Calling. Pretext calling is a fraudulent means of obtaining a person's personal information. Pretext callers may contact bank employees, posing as customers, to access customers' person- al account information. Information obtained from pretext calling may be sold to debt collection services, attorneys, and private investigators to use in court proceedings. Identity thieves may also engage in pretext calling to obtain personal information to create fraudulent accounts. Avoid Becoming a Yctim of Identify Theft and Pretext Calling. Here are some basic steps you can take to avoid becoming a victim of identity theft and pretext calling: • Do not give personal information, such as account numbers or social security numbers, over the telephone, through the mail, or over the intemet, unless you initiated the contact or know with whom you are dealing. • Store personal information in a safe place and tear up old credit card slips, ATM receipts, old account statements, and unused credit card offers before throwing them away. • Protect your PINS and other passwords. Avoid using easily available information, such as your mother's maiden name, your birth date, the last four digits of your social security number, your phone number, etc. • Carry only the minimum amount of identifying information and number of credit cards that you need. • Pay attention to billing cycles and statements. Inquire of the bank, if you do not receive a quarterly statement. It may mean that an identity thief diverted the statement. • Check account statements carefully to ensure all charges, checks, or withdrawals were authorized. • Guard your mail from theft. If you have the type of mailbox with a flag to signal that the box contains mail, do not leave bill payment envelopes in your mailbox with the flag up. Instead, deposit them in a post office collection box or at the local post office. Promptly remove incoming mail. + Order copies of your cred'R report from each of the three major credit bureaus once a year to ensure that they are accurate. You may request a free credit report once a year from each major credit bureau online, by telephone, or by mail. Yctim of Identity Theft If you believe that someone has stolen your identity, you should: + Contact the fraud department of each of the three major credit bureaus to report the identity theft and request that the credit bureaus place a fraud alert and a victim's statement in your file. The fraud alert puts creditors on notice that you have been the victim of fraud, and the ~rictim's statement asks them net to open addtional accounts without first contacting you. • The telephone numbers for the fraud departments of the three national credit bureaus are: Trans Union 1-800-680-7289 Equifax 1-800-525-6265 Experian 1-888-397-3742 You may request a free copy of your credit report. Credit bureaus must provide a free copy of your report if you have reason to believe the report is inaccurate because of fraud and you submit a request in writing. • Review your report to make sure no additional fraudulent accounts have been opened in your name or unauthorized changes made to your existing accounts. Also, check the section of your report that lists "inquiries" and request that any inquiries from companies that opened the fraudulent accounts be removed. • Contact any bank or other creditor where you have an account that you think may be the subject of identify theft. Advise them of the identity theft. Request that they restrict access to your account, change your account password, or close your account, if there is evidence that your account has been the target of criminal activity. • File a report with your local police department Contact the Federal Trade Commission's tdentity Theft Hotline toll•free at 1.877•ID•THEFT X438-4338). The Federal Trade Commission enters the information into a secure consumer fraud database and shares it with local, state, and federal law enforcement agencies. HSA Banlc~ PO Box 939 Sheboygan, WI 53082-0939 1-800-357-6246 HSA Bank is a division of Webster Bank, N.A., Member FDIC June 2008 DISC HSADISCLOSURE52008 1483 040108 v60 10