Common Contracts
1 similar Health Savings Account Agreement contracts
Health Savings Account Agreement FormHealth Savings Account Agreement • October 4th, 2019
Employer Name La Plata County Name (Last, First, MI) Employee Number Street Address City State ZIP Code Effective Date of Election Type of Election Date of Birth-MM/DD/YY New Election New Hire ElectionChange in Election Stop Election Health Savings Account Election HSA Custodian – Central Bank Per Pay Period Salary Reduction AmountCheck the medical plan coverage tier that you have enrolled in.Employee Only HDHP Coverage Family HDHP Coverage Indicate the Per Pay Period Amount that you wish to contribute to the HSA$
