Please complete the form below to submit your online medical savings account (MSA) application. You will immediately receive a confirmation email with details as to how your application is being processed. If you have any questions, please do not hesitate to contact our office and we would be more than happy to help you in any way we can.
Thank you for your business, and congratulations on your new Idaho MSA!
*Note: All fields marked with an asterisk (*) are required.
Important Information About Procedures for Opening a New Account: To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.
What This Means for You: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents.
|*Legal First NameMI*Legal Last Name*Social Security Number*Date of Birth*Contact Email*Mother's Maiden Name*Occupation*Mailing Address*City*State*Zip CodeResidential Address (If different)CityStateZip Code*Home PhoneCell PhoneWork Phone*Driver's License Number*State of Issue*Issue Date*Expiration Date|
Joint Account Owner Information:
Adding a joint account owner is optional, however this person must be your spouse and a joint Idaho tax return must be filed.
|Legal First NameMILegal Last NameSocial Security NumberDate of BirthMother's Maiden NameOccupationCell PhoneContact EmailResidential Address (if different)CityStateZip CodeDriver's License NumberState of IssueIssue DateExpiration Date|
In the event of your death, you name as your beneficiary:
|*First Name*Last Name*Relationship|
Insurance Agent Information:
|First NameLast NameAgent ID (optional)|
Insurance Plan Information: (Optional)
|Insurance CarrierEffective Date of PolicyDeductible AmountCoverage Type|
|Name of EmployerDivision #|
Tax Filing Status:
|*What is your current tax filing status in Idaho?|
Acceptance of Terms:
By entering your initials below, you are indicating that you have read, understand, and agree to the terms and conditions.
Additionally you understand that a non-refundable $36 annual fee applies to this account. The initial annual fee will be pro-rated to the following April from the date of account opening and will be deducted from your account upon initial deposit. The full $36 annual fee will then be deducted on an annual basis every April for the life of the account.
|*Enter Your Initials|