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 MSA!
*Note: All fields marked with an asterisk (*) are required.
|Patriot Act Notice: 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 that opens an account.
Account Holder Information:
|*Legal First NameMI*Legal Last Name*Social Security Number*Date of Birth*Contact Email*Mother's Maiden Name*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 NameCell PhoneDriver'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 #|
Contributing to additional tax-deferred healthcare accounts is allowable with an Idaho MSA, but there are rules to be aware of if you maintain any of these additional accounts.
|*Do you or your spouse currently have a Health Savings Account (HSA)?|
*Do you or your spouse currently have a Flexible Spending Account (FSA)?
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 $36 annual fee is required to open this account and will be deducted upon your initial deposit, and again on an annual basis thereafter for the life of the account.
|*Enter Your Initials|
By submitting this application you understand that a $36 annual fee and a $50 opening deposit will be charged to your credit/debit card as a minimum requirement to open this account.
If you would like to make a larger opening deposit than the required minimum of $50, please enter your additional opening deposit amount in the box below.
|Additional Opening Deposit|