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!
Account Holder Information:
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.
In the event of your death, you name as your beneficiary:
Insurance Agent Information:
Insurance Plan Information: (Optional)
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.
Tax Filing Status:
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.
Acceptance of Terms:
By entering your initials below, you are indicating that you have read, understand, and agree to the terms and conditions.