E

Requirements Gathering Document

2017 Health Savings Account

For:

Table of Contents

General Information3

Client Information3

HSA Custodian3

High Deductible Health Plan (HDHP)3

Beneficiaries3

Timing of Contributions3

Timing of Distributions4

Monthly Account Statements4

Contribution Maximums4

IDV/OFAC4

Terms & Conditions4

Failure to Establish4

Optional Investment Sweeps5

Health Savings Account Plan Details5

Payroll Posting6

Tax Forms6

Contribution Imports6

Enrollment Options7

Online Enrollment7

Enrollment Census7

Establishment Application 7

Participant Forms/Information9

Distribution Request Form9

Contribution Request Form9

Beneficiary Change Form9

HSA Brochure9

HSA Investment Options9

Employer Reports9

Mobile Application10

Participant Education10

Employer Portal Contacts11

Funding Process11

Funding Contacts12

Fees12

Acceptance13

General Information

Client Information

Client Name:

DBA or AKA Name:

Client Address:

Client Tax ID:

Number of Benefit Eligible:

Expected Participant

Count :______________________________

Entity Type

(S Corp, C Corp, LLC):

Industry:

Tax Year End Month and Day:

State Organized:

Controlled Group:

|_| Yes

|_| No

If yes, list Affiliates including Tax ID#

HSA Custodian

Healthcare Bank

High Deductible Health Plan (HDHP)

Enrollment in a HDHP (High Deductible Health Plan) is required to contribute to a Health Savings Account. A HDHP is a plan that features higher deductibles than traditional insurance plans and can be combined with HSAs to allow participants to pay for qualified out-of-pocket medical expenses on a pre-tax basis. Please see chart below to make sure your plan qualifies.

Beneficiaries

It is highly recommended that each HSA participant establishes primary and contingent beneficiaries. If no beneficiaries are designated, funds are subject to probate upon death. Please Note: If you are married and you do not name your spouse as 100% primary beneficiary, they must complete the spouse consent piece of the beneficiary form.

Timing of Contributions

· All contribution types, regardless of system settings, takes 2-3 business days for deductions to post to participant’s accounts.

· The earliest a contribution can be posted at the start of the calendar year is 2-3 business days after the holiday.

Although there is some formal and informal federal guidance on situations when HSA contributions can be reversed providing there is clear documentary evidence there was an administrative or process error, there is no formal or informal guidance on the below situations and therefore funds cannot be removed from the accountholder’s HSA when these occur:

1. Employee has change of coverage where they cease to be HSA eligible, yet the employer continues to contribute.

1. Employee terminates employment, but employer continues to make HSA contributions.

1. Any circumstance where there is not clear documentary evidence that demonstrates there was an administrative or processing error.

Timing of Distributions

· Distributions are processed daily (Checks or Direct Deposit)

· Checks are mailed next day

· Checks - $5.00 fee per check/Direct Deposit – FREE

· Payment preferences can be updated via the Participant Portal

· Direct Deposits are posted same day and available to participants within 1-2 business days after files are loaded.

Monthly Account Statements

· Monthly HSA Statements are required

· Statements are provided to participants on a monthly basis

· Printed statement fee is $5.00 per printed statement

· Participants can opt out of paper and into electronic statements by updating their Notification Preferences in the Participant Portal

Contribution Maximums

HSA Contribution and HDHP Minimum Deductible and Out-Of-Pocket Limits

HDHP Minimum Deductible Amount

2013

2014

2015

2016

2017

Individual

$1,250

$1,250

$1,300

$1,300

$1,300

Family

$2,500

$2,500

$2,600

$2,600

$2,600

HDHP Maximum Out-of-Pocket Amount

2013

2014

2015

2016

2017

Individual

$6,250

$6,350

$6,450

$6,550

$6,550

Family

$12,500

$12,700

$12,900

$13,100

$13,100

HSA Statutory Contribution Amount

2013

2014

2015

2016

2017

Individual

$3,250

$3,300

$3,350

$3,350

$3,400

Family

$6,450

$6,550

$6,650

$6,750

$6,750

Catch-Up Contributions (age 55 or older)

2013

2014

2015

2016

2017

Individual

$4,250

$4,300

$4,350

$4,350

$4,400

Family

$7,450

$7,550

$7,650

$7,750

$7,750

IDV/OFAC

All HSA accounts established request IDV/OFAC Verification.

IDV – Identify Verification Process – A banking requirement that comes from the US Patriot Act Bill signed into law in 2001.

OFAC – Office of Foreign Assets Control – Part of the US Department of the Treasury that administers and enforces economic and trade sanctions.

Document to support account validation may be requested. Participants have 60 days from account establishment to submit requested documentation before the initiation of account closure.

Terms & Conditions

In addition to passing the IDV/OFAC verification process, all participants must accept the terms and conditions.

Failure to Establish

If either the account does not pass IDV/OFAC verification and/or the Terms and Conditions have not been accepted after 60 days from account establishment, the account will be closed and any pending contributions will be returned to the employer.

Optional Investment Sweeps

Participants can opt into auto investment sweeps. Minimum threshold is $2,000. If selected, funds are automatically sweep into the investment account once the available cash balance exceeds the sweep threshold amount by $100 or more. Likewise, when the available cash balance falls below the sweep threshold by $100 or more, funds will automatically sweep back to the cash account from the investment account. If auto investments are not selected, funds will remain in a cash account.

Health Savings Account Plan Details

Please provide information about the required spending account plans by completing the information below.

Plan Name: HSA

Description: Health Savings Account

Plan Year Begin:

Company Contribution: |_| Yes |_| No

If Yes, Amount: $

If Yes, Frequency:

Debit Card Expenses Allows: |_| All Expenses |_| 213 Expense Only

*Custom Logo on Debit Card: |_| Yes |_| No

*Single color logo card - $500 fee, Multiple colored logo card – $1,000 + (discussion during implementation)

**Terminated employees will utilize the card with the company Logo upon termination.

Divisions (If applicable):

**Expense Tracker Feed: |_| Yes |_| No **Subject to carrier guidelines

Medical Carrier:

Will a post-deductible HRA also be offered in conjunction with the HSA? |_| Yes |_| No

Will a Limited Purpose FSA also be offered in conjunction with the HSA? |_| Yes |_| No

**if implementing Post-Deductible HRA and/or LPFSA additional paperwork and fees may apply.

Payroll Posting - Please choose one of the following options below

Posting of payrolls to an HSA account takes approximately 2-3 business days to be available to participants while transmitting through the banking process. There are two options to post payroll contributions.

|_| Option 1 - Auto Post Once Confirmed Via File – File will import immediately and will not wait until payroll date to start banking process. Funds will take approximately 2-3 business days to post from file import date. PLEASE NOTE: Files for a future calendar year cannot be posted until the year begins or contributions could be erroneously posted to a prior tax year. Example: First payroll date in January is 1/4, the contribution file should not be posted until 1/1 or later to avoid being picked up in the prior tax year.

|_| Option 2 – Auto Post on Payroll Date – Files imported will wait until the payroll date (determined via a schedule) to begin the banking process. Once the payroll date arrives the 2-3 day banking process will begin. This approach is not an issue during the new calendar year. Example: First payroll date in January is 1/4, the contribution file will wait until 1/4 to begin the 2-3 day banking process, no matter when the file is actually posted.

These options affect all plan types administered by Benefit Strategies, LLC including HCA, DCA, HRA and Commuter Choice plan types. If option 1 is selected, all payrolls, including CDH plans, will need to be imported. CDH payroll funds are available on the day imported and are not subject to the 2-3 business day processing time.

Tax Forms

Healthcare Bank’s standard delivery method for 1099-SA and 5498-SA tax forms will be electronically, through the HSA Participant Portal.

Forms will be maintained in the HSA Participant Portal for seven (7) years.

· Form 1099-SA – Distributions

· Form 5498-SA – Contributions

Must include yearly total of contributions in form 8889 with tax forms

Contribution Imports

IMPORTANT INFORMATION: Contributions are imported into the administrative system by the Employer via the Employer Portal. Access will be sent to the contact provided whom will be responsible to process the import. All HSA contributions take 2-3 business days to clear the banking process and be available to participants.

For further training and instructions on processing the HSA Import for Employer and Employee Contributions.  Please schedule a webinar to review the process after the implementation is complete and the account has been assigned to your day to day contact.

Enrollment Options

Benefit Strategies, LLC provides various flexible enrollment options for Health Savings Accounts. Please see our available options below and check the appropriate option.

Important: All participants must provide a physical address to establish an HSA account. A PO Box will not be accepted per IRS regulations.

*If recurring eligibility file being sent consumers ability to make profile changes will be turned off.

Online Enrollment

|_| Online Enrollment is the most quick and efficient way to establish a Health Saving Account. The demographic census must be provided to Benefit Strategies to allow us to set up system access before the online process begins. Please also provide the dates for the online enrollment process to be open below (needs to end prior to plan administration start). The online process includes all aspects of enrollment including accepting the Terms & Conditions and beneficiary designation options.

Online Enrollment Start Date:Online Enrollment End Date:

Enrollment Census

|_| The Enrollment Census includes all information for enrollment into a Health Savings Account, including beneficiary information. PLEASE NOTE: A separate process to accept the Terms and Conditions must be completed to finalize enrollment. Options include verifying within the Participant Portal or via paper (additional fees will apply).

Establishment Application

|_| The HSA Establishment Application includes all information for Establish a Health Savings Account, including beneficiary information. PLEASE NOTE: A HSA confirmation email from Benefits Strategies will be sent with Account Login information and participants will be required to login and accept the Terms and Conditions in order to finalize enrollment. (Fees May Apply)

Ongoing Eligibility

The HSA Establishment Application can be used for ongoing eligibility. It is the Employers responsibility to enter and update ongoing enrollments once account is set up and active. Access to the online portal will be provided at that time for ease of use to update these changes throughout the plan year. Please see your assigned Account Manager if you have any questions.

Participant Communications

Email notifications are sent to active participants with an email address when the letters below are generated. The email notification informs the participant the associated letter is available for viewing via the Participant Portal.

Health Savings Account Participant Notifications

· Advice of Deposit for HSA Distribution

· Enrollment Confirmation Open-Ended Plan Year

· HSA Account Closure

· HSA Account Summary

· HSA Cash Balance Notification

· HSA Contribution Maximum Notification

· HSA Contribution Notification

· HSA Payment Issued Notification

· HSA Tax Document

· HSA Recurring Contribution Created

· HSA Recurring Contribution Updated

· HSA Recurring Contribution Cancelled

· HSA Withdrawal Notification

Custom Logo for Spending Account Self Service Home Page

Indicate if a client logo will be displayed on the Participant Portal home page.

|_| No: Do not display the client logo on the Participant Portal home page.

|_| Yes: Provide a JPG, GIF, or PNG file. The logo may be in color and must be no taller than 75 pixels and no wider than 190 pixels.

Participant Forms/Information

Each form will be displayed for participants to download from the Participant Portal.

Sample Health Savings Account Forms

Distribution Request Form

Used to file Distributions, Rollovers (to self) or Transfers (to another custodian).

Contribution Request Form

Used for the manual contribution of funds into your Health Savings Account.

Beneficiary Change Form

Used to add or update beneficiary information. Also used as a Spousal Consent form if spouse is not 100% primary beneficiary.

HSA Brochure

Informational material for participants about a Health Savings Account.

HSA Investment Options

View the investment options currently available to HSA participants.

Employer Reports

Plan Management Reports

HSA Account Detail Report

HSA Employer Summary Report

· Reports are scheduled to run on a monthly basis.

· Reports are posted on the Employer Portal for access by Employer Portal users.

· Reports will be provided in an MS Excel format when this option is available, but a PDF may be requested instead if this format is required.

Mobile Application

Benefit Strategies Reimbursement Plan

Benefit Strategies is offering the ability for iPhone or Android users to access their account information directly through their phone.

Participants can access the following information through the application:

· Check available balances

· Request Distributions

· Make a Contribution

· Convenient customer service contact information

Participant Education

Participant Account Demo – Introduction to Health Savings Account:

Participant Account Demo – Distribution of HSA Funds:

Participant Account Demo – Contribution to HSA Account:

Employer Portal Contacts

Enter information below for each client Human Resources contact requiring access to view employer reports via the Employer portal. A notification will be sent to each contact with information regarding use of the Employer Portal.

Please list the client Human Resources contacts below who require a logon and password for access to the employer portal.

Primary Human Resources Contact

Name:

Title:

Email:

Phone Number:

Portal Access: |_| Yes |_| No

Secondary Human Resources Contact

Name:

Title:

Email:

Phone Number:

Portal Access: |_| Yes |_| No

Human Resources (Other)

Name:

Title:

Email:

Phone Number:

Portal Access: |_| Yes |_| No

Human Resources (Other)

Name:

Title:

Email:

Phone Number:

Portal Access: |_| Yes |_| No Number:

Funding Process

Overview

EFT funding is required for HSA Accounts. Please complete the EFT Funding agreement attached and return to Benefit Strategies, LLC immediately to avoid delay in setup. Funds for contributions are pulled from the Employer’s bank account once the contribution has settled. Posted contributions take approximately 2-3 business days to settle. Funds are pulled daily.

Unclaimed Checks

Clients will address the escheatment and/or other handling of unclaimed checks that have reached the 180 day expiration date.

A report of unclaimed checks will be provided upon request.

Funding Contacts

Please list the client funding contacts below who should receive invoicing from Benefit Strategies, LLC

Funding Contact

Name:

Title:

Email:

Phone Number:

Funding Contact

Name:

Title:

Email:

Phone Number:

Fees

Set-Up Fee

$Waived

Renewal Fee

$Waived

Administration Fee (Active Employee)

$2.95 per account per month deducted from HSA

Administration Fee (Individual Termed Account)

$4.00 (month) deducted from HSA

Initial Set of Debit Cards (Cards come in a set of 2)

$Waived

Additional/Replacement Cards (Cards come in a set of 2)

$Waived

Non-Discrimination Testing Fee (Not required if no Employer Contribution)

$400 upon request

Check Fee

$5.00 (per check) deducted from HSA

Account Closure Fee

$18.00 deducted from HSA

Printed Account Summary Fee

$5.00 (per account summary) deducted from HSA

Fee Invoicing Method

EFT Required

Special Notes

*As long as an employee has an active HSA account containing funds, the administrative fee will apply.

Acceptance

I have reviewed and approved the contents of the Health Savings Account Requirements. I certify that the contents of the Health Savings Account Requirements have been documented in a manner that accurately reflects the Health Savings Account for Client. I also understand that after the official “sign off” of the Health Savings Account Requirements and applicable best practice recommendations are received, administration will begin based on the information detailed in the Health Savings Account Requirements.

Name:

Title:

Date:

Signature:

All implementation documents, once complete, should be returned directly to your implementation specialist. Email to implementation@benstrat.com

Employer Checklist

Please use the provided checklist to help organize your implementation requirements.

☐

Completed Requirements Gathering Document including plan details

☐

Payroll Option Selected

☐

Payroll Calendar Provided (If applicable)

☐

Enrollment Option Selected

☐

Online Enrollment Census Provided (If applicable)

☐

Online Enrollment Start and End Dates established (Required if Online Enrollment selected)

☐

Enrollment Template Provided (If applicable)

☐

Paper Enrollment Forms Provided (If applicable)

☐

Terms & Conditions method established (Only applicable if Enrollment Template is used)

☐

Logo provided to Benefit Strategies (If applicable)

☐

Informational material provided to employees (If desired)

☐

HR Contacts listed for portal access and communications

☐

Financial Contacts listed for billing purposes

☐

EFT Funding Agreement completed and returned to Benefit Strategies

☐

Requirements Gathering Document Signed

Entering HSA Contributions.pdf

Funds are added to the consumer account through the employer import file uploaded through the employer portal. The template used has 5 fields that are required to add funds to the consumer’s account.

Hovering over the selected fields give further information regarding format and content.

To import a file, the link for “Import Data” should be selected.

Once the import data from file page opens, the template will be present under Select a Template. Once completed, the file can be selected in the Upload File field. Import Data can then be selected.

Once the import is complete, there is a notification sent. This report will indicate if any records on the import file failed. Please reach out to your account manager if assistance is needed to correct the error.

HSA Employer

ContributionTemplate.xlsx

Employer Contribution TemplateEmployeeIdentifierContributionDateContributionDescriptionContributionAmountPlanName

HSA Online

Enrollment Template.xlsx

Company INFOElectronic Download Template - Online Enrollment

Please send completed forms to: implementation@benstrat.com

Company Name:Contact:Telephone Number:Email Address:

*Please see Instructions tab for file naming conventions.

Instructions

"EmployeeInformation" TabFieldRequiredFormatLengthDescriptionEmployer NameYText75Employer Full NameParticipant EEID NumberYText55Employees Employee ID issued by Employer (No dashes)Participant SSNYText9Employees Social Security Number (000000000 no dashes)Participant First NameYText25Employees First Name (Dashes & apostrophes are OK)Participant Middle NameNText1Employees Middle Initial (No periods and only 1 letter)Participant Last NameYText45Employees Last Name (Dashes & apostrophes are OK)Participant Email AddressNText350Employees E-Mail AddressParticipant Address1YText50Employees Address (No Punctuation)Participant Address2NText50Additional Address Line (No Punctuation)Participant CityYText45Employees City (No Punctuation)Participant StateYText35Employees StateParticipant Zip CodeYText5Employees 5 Digit Zip Code (00000)Participant Hire DateYDate (mm/dd/yyyy)10Employee Date of HireParticipant Home PhoneNText12Employees Home Phone Number (xxx-xxx-xxxx)Participant Work PhoneNText12Employees Work Phone Number (xxx-xxx-xxxx)Participant Payroll FrequencyYText3Employment payroll frequency. Must be a system defined format (see Format). Must coordinate with payroll frequencies defined within the employer account. This field is case sensitive and must be in all CAPS. Key is as follows W = Weekly or 52 Pay periods/ year B26 = 26 pay periods/ year B24= 24 pay periods/ year (If 3 pay periods would otherwise occur in a month, this frequency drops the third, allowing for only 2 pay periods in that month.) S1 = 1st and 15th of each month for a total of 24 pay periods S15 = 15th and 30th or 31st of each month for a total of 24 pay periods M = Monthly for a total of 12 Pay periods O=Other (If you choose Other (O), please include a Pay Frequency Schedule so that the information we enter into the system is correctParticipant DivisionYText75Division Name if applicable; defaults to "Unassigned" if no divisions are listedParticipant Date of BirthYDate (mm/dd/yyyy)10Employees Date of BirthParticipant GenderYText1Employees Gender (M or F)File Naming Convention:Online Enrollment Census Files:_OE_FSAQS_mmddyyyy.xls

EmployeeInformationEmployer NameParticipant EEID NumberParticipant SSNParticipant First NameParticipant Middle NameParticipant Last NameParticipant Email AddressParticipant Address1Participant Address2Participant CityParticipant StateParticipant Zip CodeParticipant Hire DateParticipant Home PhoneParticipant Work PhoneParticipant Payroll FrequencyParticipant DivisionParticipant Date of BirthParticipant GenderSample Company Name72368123456798AndreaMMaloneyamaloney@noemail.com123 Main StreetAnywhereNH031026/25/99603-555-1212603-555-1313B26Unassigned6/25/05F

mailto:amaloney@noemail.commailto:amaloney@noemail.com

HSA Online

Enrollment Instructions-OpenEnded.pdf

1

Consumer HSA Online Open Enrollment Quick Reference Guide You may enroll online for HSA during a specified period before the plan year start date as well as at any time during the plan year. Please refer to the steps below for additional information regarding on-line enrollment. Login Step 1: Log in to your secure account by going to www.benstrat.com and clicking on the Reimbursements Secure Account Login button on the top right corner of the Home Page.

Login Step 2: Choose Employee/Participant Login

Login Step 3: Log in as existing user or new user

Existing Users

Existing Users can continue to use their existing username and password already created.

New Users New Users to the website may

create a new account anytime by selecting the “New User” link and follow the registration instructions.

http://www.benstrat.com/

2

Enrolling Step 1: After logging in you’ll be brought to your secure account Home page. Begin online enrollment by clicking the HSA Enroll Now link.

Enrolling Step 2: Review the Summary of Pre-Tax Benefits. Click Next to continue.

Enrolling Step 3: Enter demographic and contact information. Click Next to continue.

Fields with a red asterisk (*) are required.

Your social security number is required to set up your HSA account.

Your email address allows you to receive notifications and other important information quickly.

3

Enrolling Step 4: If you will be enrolling in Individual coverage do not list any dependents. Click Next to continue. If you will be enrolling in Family coverage, enter each dependent and click the Add Dependent button after each one. Click Next to continue once you have added all dependents.

Enrolling Step 5: Review the HSA Qualifications and then check that you certify that you are eligible for a Health Savings Account. The Qualifying Health Plan Coverage options on this screen vary depending on your plan. Make your choices and Click Next to continue. Note: If you haven’t added any dependents in Step 4 and you choose Family Coverage level in Step 5, you will not be able to submit your enrollment until you have added dependents or changed coverage level to Individual.

Enrolling Step 6: Select your Payment Methods. This is how you’ll access your HSA funds, so you will want to choose to have the debit card issued to you. When you request distributions from your HSA account, choose if you want to receive them via Direct Deposit or check mailed to your home address. Click Next to continue.

4

If selecting Direct Deposit, you’ll be asked to enter your bank account information. The bank information may populate based on the routing number entered. If not, enter the contact information for your bank.

Enrolling Step 7: Designate beneficiaries. If you entered dependents earlier, they will be listed on this screen for easy selection if naming as a beneficiary. After completing the information for a beneficiary click Add Beneficiary. During online enrollment, you must name your spouse as a primary beneficiary if you are married. You may choose to change this later by submitting a notarized Beneficiary/Spousal Consent Form with your spouse’s signature of consent to Benefit Strategies. After adding all primary and contingent beneficiaries, click Next to continue.

Enrolling Step 8: Check that you have read and agree with the Designated Representative Agreement, the HSA Custodial Agreement and Disclosure Statement and the Patriot Act Requirement. Click Next to continue.

5

Enrolling Step 9: Verify your Enrollment Summary information carefully. Click Update in any of the sections to make corrections. Click Next to continue.

Enrolling Step 10: The final step is to complete the HSA Account Creation Authorization requesting that an HSA be opened in your name. Click Submit Enrollment.

After clicking Submit Enrollment, you’ll be presented with an enrollment confirmation screen. This is your indication

that your enrollment is complete. If you don’t see the enrollment confirmation screen, please contact Benefit Strategies at 888-401-3539.

ET-HSA-Enrollment-

Template.xlsx

Company INFOElectronic Download TemplatePlease send completed forms to: enrollments@benstrat.com

Company Name:Contact:Telephone Number:Email Address:

*Please see Instructions tab for file naming conventions.

Instructions

"EmployeeInformation" TabClick Here for File Naming Convention InformationFieldRequiredFormatLengthDescriptionEmployer NameYText75Employer Full Name (Required for eligibility)Please do not use any punctuation in any of the fieldsParticipant StatusYText16Employees Status (Active, Terminated, LOA (Leave of Absence), COBRA) (Required for eligibility)1. One line per plan per employee Participant Status Effective DateYDate (mm/dd/yyyy)10Employees Status Effective Date (IE hire date, LOA effective date, COBRA effective date)2. Do not add additional columns to the worksheetParticipant Status Reason for ChangeNText36Employees Status Change ReasonParticipant EEID NumberNText55Employees Employee ID issued by Employer (No dashes) Participant SSNYText9Employees Social Security Number (000000000 no dashes) (Required to establish an HSA)Participant First NameYText25Employees First Name (No Punctuation including dashes & apostrophes) (Required for eligibility)Participant Middle NameNText1Employees Middle InitialParticipant Last NameYText45Employees Last Name (No Punctuation including dashes & apostrophes) (Required for eligibility)Participant Email AddressNText350Employees E-Mail AddressParticipant Address1YText50Employees Address (No Punctuation) (Required for eligibility)Participant Address2NText50Additional Address Line (No Punctuation)Participant CityYText45Employees City (No Punctuation) (Required for eligibility)Participant StateYText35Employees State (Required for eligibility)Participant Zip CodeYText5Employees 5 Digit Zip Code (00000) (Required for eligibility)Participant Hire DateYDate (mm/dd/yyyy)10Employee Date of Hire (Required for eligibility)Participant Home PhoneNText12Employees Home Phone Number (xxx-xxx-xxxx)Participant Work PhoneNText12Employees Work Phone Number (xxx-xxx-xxxx)Plan NameYText15Plan Name employee enrolled in (HSA). Required for eligibilityParticipant Payroll FrequencyYText3W = Weekly or 52 Pay periods/year; B26 = 26 pay periods/year; B24= 24 pay periods/year; (If 3 pay periods would otherwise occur in a month, this frequency drops the third, allowing for only 2 pay periods in that month.) S1 = 1st and 15th of each month for a total of 24 pay periods; S15 = 15th and 30th or 31st of each month for a total of 24 pay periods; M = Monthly for a total of 12 Pay periods; O=Other (If you choose Other (O), please include a Pay Frequency Schedule so that the information we enter into the system is correct (Required for eligibility)Participant DivisionYText75Division Name if applicable; default to "Unassigned" if no divisions are listed (Required for eligibility)Participant ClassYText50Employer Benefit Eligible Criteria; Default to "All Employees".Enrollment Effective DateYDate (mm/dd/yyyy)10Date the Plan Year is Effective (Required for eligibility)Annual Participant ElectionYText7Annual Election amount, can be $0 for HSA. Must be $0 for open-ended HSAs. No comma (0000.00) (Required for eligibility)Election Amount IndicatorYText14Indicates the type of election amount entered (Plan Year or Per Pay Period). This field only pertains to the participant’s election amount if not 0. Annual Employer ContributionYText7Employer Contribution if any; default to zero if employer does not contribute to plan; No comma (0000.00)Participation LevelYText9Valid values are Ind, IndSpouse, IndChild and Family.HDHP Coverage LevelYText6The participant’s enrollment level in a qualified HDHP. Valid values are Single or Family.Terms and Conditions IndicatorYText1Indicates whether the client is using an indicator when the consumer has accepted the terms and conditions of their HSA.Date Terms Conditions AcceptedYDate (mm/dd/yyyy)10The date that the consumer accepted the terms and conditions of their HSA. Primary Reimbursement MethodYText14New Plan Year's Reimbursement Method defaults to prior Method if not indicated (Check, Debit Card, Direct Deposit)Alternate Reimbursement MethodNText14New Plan Year's Alternate Reimbursement Method defaults to prior Method if not indicated (Check, Debit Card, Direct Deposit)Participant Date of BirthYDate (mm/dd/yyyy)10Employees Date of Birth (Required for eligibility)Participant GenderYText1Employees Gender (M or F) (Required for eligibility)Participant Marital StatusNText1Employees Marital Status (M = Married; S = Single; D = Divorced) Bank Account TypeNText1Bank Account Type (C=Checking; S=Savings)Bank NameNText45Bank Name (No Punctuation)Routing NumberN9 Digit Number (Text Field)9List Bank Routing Number (Located on bottom left side of check)Account NumberNText30List Bank Account Number. (Leave field as text field to capture preceding zeros)

"BeneficiaryInformation" TabFieldRequiredFormatLengthDescriptionParticipant IdentifierYText50Unique identifier used to identify participants and their dependents when data about them is supplied through the import file. (Participant SSN)Beneficiary SSNYText20Unique identifier used to identify beneficiaries when data about them is supplied through the import fileRelationshipYText9Spouse, Dependent, OtherLast NameYText30Last name of the beneficiaryFirst NameYText30First name of the beneficaryMiddle InitialNText1Middle initial of the beneficiaryDOBYDate8Birth date of the beneficiaryStatusNText8Active, InactiveBeneficiary TypeYText10Primary, ContingentShareYNumeric3Indicates the percentage share for the beneficiaryAddress Line 1YText50Beneficiary's Address Line 1Address Line 2YText50Beneficiary's Address Line 2CityYText50Name of the city of the beneficiary's addressStateYText2State code of the beneficiary's addressZip CodeYNumeric5 or 9 or 10Zip code of the beneficiary's address. Note: if the zip code is sent with a dash, the dash must be between the 5th and 6th digits (total of 10 characters)CountryNText2ISO Standard two-character codes (US, CA, etc.)

File Naming Convention:Annual Enrollment Census Files:_OE_HSA_mmddyyyy.xlsxOngoing Production Files:_HSA_mmddyyyy.xlsxTest Files:_TEST_HSA_mmddyyyy.xlsx

EmployeeInformationEmployer NameParticipant StatusParticipant Status Effective DateParticipant Reason For ChangeParticipant EEID NumberParticipant SSNParticipant First NameParticipant Middle NameParticipant Last NameParticipant Email AddressParticipant Address1Participant Address2Participant CityParticipant StateParticipant Zip CodeParticipant Hire DateParticipant Home PhoneParticipant Work PhonePlan NameParticipant Payroll FrequencyParticipant DivisionParticipant ClassEnrollment Effective DateAnnual Participant ElectionAnnual Employer ContributionParticipation LevelPrimary Reimbursement MethodAlternate Reimbursement MethodParticipant Date of BirthParticipant GenderParticipant Marital StatusBank Account TypeBank NameRouting NumberAccount NumberSample Company NameActive6/25/997990012123456798AndreaMMaloneyamaloney@noemail.com123 Main StreetAnywhereNH031026/25/99603-555-1212603-555-1313HCAB26UnassignedAll Employees1/1/1425000Debit CardDirect Deposit12/14/88FSCheckingBank Name1234567890987654785123525

mailto:amaloney@noemail.commailto:amaloney@noemail.com

BeneficiaryInformationParticipant IdentifierBeneficiary SSNRelationshipLast NameFirst NameMiddle InitialDate of BirthStatusBeneficiary TypeShareAddress Line 1Address Line 2CityStateZip CodeCountry111223333999887777DependentSampleSusanM1011970ActivePrimary100123 Sample St.Apt. #2CityST12345US

HSA Establishment

Application.pdf

HSA ESTABLISHMENT APPLICATION

A. Accountholder Information All fields are required

Please note: As a part of the U.S. Patriot Act of 2001, financial institutions must verify the identity of any person seeking to open an account. If the information provided in Section A cannot be verified via the ID verification process, we will contact you to obtain documentation to validate the accuracy of the information. HSA funds will be on hold until the ID verification hold has been cleared. If not cleared within 60 days of notice, your HSA will be closed and any funds returned to the originating account.

Please Print Clearly To Ensure Your Account Is Set Up Accurately!

Company Name:

Name: (Last, First, MI)

Social Security Number:

Street Address: (Cannot be PO Box)

City: State: Zip Code: Day Phone: ( )

E-mail Address*:

Required to receive important account notifications

Date of Birth:

Date of Hire: Gender: F M

Division (if applicable):

B. Medical Plan Information For the HSA-Qualified High Deductible Health Plan (HDHP)

HDHP Effective Date: HDHP Coverage Level: Self Only Family/Other

C. HSA Effective Date

Please indicate your HSA effective date. The chart below can help you determine your appropriate effective date. If HDHP Effective Date Is: And Application Signature Date Is: The HSA Effective Date Can Be:

First of month On or prior to HDHP effective date HDHP effective date or any later date Example: January 1 Example: December 15 Example: January 1 or later date

First of month After HDHP effective date Date of application or any later date Example: January 1 Example: January 2 Example: January 2 or later date

Other than first of month On or before 1st of month following HDHP effective date 1

st of month following HDHP effective date or later

Example: January 15 Example: January 25 Example: February 1 or later date

Other than first of month After the 1st of month following HDHP effective date Date of application or any later date

Example: January 15 Example: February 2 Example: February 2 or later date

HSA Effective Date:

D. Debit Card

E. Distribution Request

You can request a distribution of funds from your HSA easily through your secure online account at benstrat.com. You can also complete and submit the HSA Distribution form. The form can be downloaded from benstrat.com or you can contact Benefit Strategies to have the form sent to you. Indicate below how you would like to receive the funds when you request a distribution.

Direct Deposit – No fee. Please complete below. Check – $5.00 fee applies for each check distribution.

Direct Deposit Information

Bank Name:

(See #1 on sample)

Checking Account

Savings Account

Routing Number: 9 digits (See #2 on sample):

Account Number:(See #3 on sample):

___________________________

You will automatically receive a set of two identical debit cards that you can use to access HSA funds when paying at the point of service/sale or when paying a bill. Debit cards will be mailed to your home address in an envelope that looks like this. You will sign the back of one card and an eligible dependent can sign the back of the other card for his/her use. Additional and replacement cards can be ordered by contacting Benefit Strategies at 888-401-3539 or info@benstrat.com. Fee may apply.

*Your email address will not be shared, sold or used for purposes other than contacting you regarding your HSA.

F. Beneficiary Designation

I designate the following individual(s) or entity as my primary or contingent death beneficiary(ies) of this HSA. If I am married in common law or in a community or marital property state, I must designate my spouse as Primary Beneficiary unless my spouse’s signature is obtained and notarized below.

Share percentages must equal 100% for primary and 100% for contingent.

1. Name: Social Security Number:

Address: (City, State Zip) Date of Birth:

Primary or Contingent Spouse Dependent Other

Share Percentage:

2. Name: Social Security Number:

Address: (City, State Zip) Date of Birth:

Primary or Contingent Spouse Dependent Other

Share Percentage:

3. Name: Social Security Number:

Address: (City, State Zip) Date of Birth:

Primary or Contingent Spouse Dependent Other

Share Percentage:

Please check one of the following:

I am not married. If I become married at a future date, I understand I must complete a new Beneficiary Designation form.

I am married. I understand that if I choose to designate a primary beneficiary other than my spouse, he or she must agree to the designation by signing below. My spouse’s signature must be notarized.

Notarized Signature of Spouse: (Only required if spouse is

waiving beneficiary rights)

Date:

Subscribed and sworn to before me this ______ day of ____________20___

_____________________________________________________________ Notary Public

G. Signature And Acknowledgements

By executing this form: I acknowledge that I understand I will receive an HSA confirmation email from Benefit Strategies with account login instructions and I am then responsible for logging in to my account at www.benstrat.com accepting Terms and Conditions. I understand that until I do so, I will not have any access to contributions made to my HSA from any source. I acknowledge that I will read the HSA Disclosure Statement and HSA Custodial Agreement (including Privacy Policy) online at www.benstrat.com and agree to receive future notices of updates by visiting www.benstrat.com, and to review the Custodial Agreement (and Privacy Policy) no less frequently than annually. (Privacy Policy can also be viewed by visiting www.healthcarebank.com) I understand that by opening an HSA I am consenting to receive electronic documents, including the monthly HSA Account Statement, and that if I want to opt out of electronic documents I can do so by requesting the change through the Statements & Notifications area of my secure account at www.benstrat.com and. A fee may apply for each paper HSA Account Statement sent.

Employee Signature: Date:

09.28.2016

http://www.healthcarebank.com/

HSA Distribution

Request Form.pdf

HSA DISTRIBUTION REQUEST FORM

1. Use this form to request a distribution from your HSA for one of the reasons indicated below.

2. Mail or fax the completed form ATTN: Finance Department to 603-647-4666 or Benefit Strategies, LLC P.O. Box 1300, Manchester, NH 03105-1300

3. If you have any questions regarding your HSA plan, please call 1-888-401-3539

A. Accountholder Information Name: (Last, First, MI)

Social Security Number:

Street Address: (Cannot be PO Box)

City: State: Zip Code: Day Phone: ( )

E-mail Address*: *Required to receive important account notifications

Date of Birth:

Date of Hire: Gender: F M Division (if applicable):

B. Distribution Request – This directs Benefit Strategies to make a distribution from your HSA for the following reason. (Choose ONE per form) B.1- Normal/Disability/Prohibited Transaction Distribution

Normal - For payment of qualified medical expenses; save your receipts.

Disability - If the disability renders you unable to engage in any substantial gainful activity and it is medically determined that the condition will last continuously for at least 12 months or lead to your death. Disability distributions are subject to income tax.

Prohibited Transaction – Use of HSA funds or anything other than a qualified medical expense; if not corrected in a timely manner, IRS penalties may be imposed.

Amount of Distribution: $__________________________

B.2- Excess Contribution Removal Excess Contribution Removal

Amount of Excess Contribution: $___________________

Earnings on Excess Contribution*: $_________________ *Benefit Strategies will work with Healthcare Bank to calculate this amount.

Date excess contribution occurred: _____________________

B.3- Rollover/Transfer- If I am requesting account closure, I authorize the TPA to liquidate the investments in my HSA Investment Account and wait 10 days to allow any outstanding debit card transaction (if debit card is applicable to my account) to settle before mailing the check for any remaining account balance, less any applicable account closing fee.

Rollover- Check will be made payable to HSA Accountholder and mailed to your address on file. Please Liquidate: $__________________________ or My entire account balance: $__________________________

Please confirm whether this rollover will close your account: YES NO

The IRS Code limits the number of rollovers that may be taken, how quickly the rollovers must be completed and how the trustee or custodian must report the transaction. If you need additional information, please contact your tax advisor. By selecting this option, you are certifying to the bank that you have satisfied the rules and conditions applicable to your rollover and that you are making an irrevocable election to treat the transaction as a rollover. The funds you receive from the distribution of an HSA must be deposited into another HSA within 60 days from when you receive them. You are entitled to one distribution per year per HSA which may be rolled over. You are entitled to roll over the same assets only once in a twelve (12) month period.

Transfer- Check will be made payable to the receiving Administrator/Trustee/Custodian for the benefit of the HSA Accountholder and mailed to the address you provide below. It is the HSA Accountholder’s responsibility to forward the check to the new Administrator/Trustee/Custodian.

Please Liquidate: $__________________________ or My entire account balance: $__________________________

Please confirm whether this rollover will close your account: YES NO

Name of Receiving Administrator/Trustee/Custodian: _______________________________________________________

Address of Receiving Administrator/Trustee/Custodian: _____________________________________________________

C. Signature And Acknowledgements

I certify that I am the HSA Accountholder or an individual authorized to execute this transaction. I have read and understand the instructions and any rules or conditions relating to this transaction. I assume full responsibility for this transaction and will not hold Benefit Strategies or Healthcare Bank liable for any adverse consequences that may result. I have not received tax or legal advice from Benefit Strategies or Healthcare Bank and, if necessary, will seek the advice of a tax or legal professional to ensure my compliance with related laws. All information provided by me is true and correct and may be relied upon.

HSA Accountholder Signature: Date:

HSA Contribution

Request Form.pdf

HSA CONTRIBUTION FORM

1. Use this form to make a contribution to your HSA using post-tax dollars.

2. Mail this completed form and your check or money order, made out to Benefit Strategies, LLC, to: ATTN: Finance Department, Benefit Strategies, LLC

P.O. Box 1300, Manchester, NH 03105-1300

3. If you have any questions regarding your HSA plan, please call 1-888-401-3539

A. Accountholder Information All fields are required Please note: This form is used only for contributing to an existing HSA. If opening a new Health Savings Account, please enroll online or complete the designated Application to set up an HSA. Name: (Last, First, MI)

Social Security Number:

Street Address: (Cannot be PO Box)

City: State: Zip Code: Day Phone: ( )

E-mail Address*: *Required to receive important account notifications

Date of Birth:

Date of Hire: Gender: F M Division (if applicable):

B. Contribution Request – Please indicate the amount of your contribution and the tax year in which you want the funds applied. Contributions for the prior tax year are permitted until the tax filing deadline (typically April 15th).

Apply my contribution of $______________ to the 20___ ___ tax year.

C. Signature And Acknowledgements

By executing this form: I request that Benefit Strategies, LLC process this contribution. I certify that the information I have provided above is correct, and I accept the responsibility of any tax consequences associated with this transaction.

Employee Signature: Date:

Funds may not be available for immediate disbursement.

HSA-Beneficiary-Change-Form.pdf

HSA BENEFICIARY CHANGE/SPOUSAL CONSENT FORM Instructions

1. Use this form to designate or change your beneficiary. If you are married in common law or in a community property or marital property state, you must designate your spouse as your Primary Beneficiary. If you wish to designate someone other than your spouse, your spouse must agree by signing in the Spousal Consent section. Your spouse’s signature must be notarized.

2. Forward completed form to: [Enter TPA Name] (TPA) at: [Enter TPA Address, City, State and Zip Code].

3. For any questions regarding changing your beneficiary, please call [Enter TPA Telephone Number].

Accountholder Information Last Name First Name Middle Initial

Social Security Number Employee ID and Employer (if applicable)

Telephone Number E-mail Address

Beneficiary Designation

I designate the following individual(s) or entity as my primary or contingent death beneficiary(ies) of this HSA, and I hereby revoke all prior death beneficiary designations made by me. Share percentages must equal 100% for primary and 100% for contingent. No. Name and Address Date of Birth Social Security Number

Primary or Contingent Relationship

Share %

1. Primary Contingent

Spouse Dependent Other

2. Primary Contingent

Spouse Dependent Other

3. Primary Contingent

Spouse Dependent Other

Spousal Consent (for HSA Accountholders married in common law or in a community property or marital property states)

I am not married and I understand that if I become married in the future, I must complete a new HSA Beneficiary Change/Spousal Consent Form. I am married and I understand that if I choose to designate a primary death beneficiary other than my spouse, my spouse must agree to the

designation by signing below. My spouse’s signature must be notarized. Subscribed and sworn to before me this Signature of Spouse _____________ day of _____________________, 20_____ Date Notary Public

Signature

I certify that I am the HSA Accountholder or an individual authorized to execute this transaction. I assume full responsibility for this transaction and will not hold TPA or Healthcare Bank liable for any adverse consequences that may result. I have not received any tax or legal advice from TPA or Healthcare Bank and, if necessary, will seek the advice of a tax or legal professional to ensure my compliance with related laws.

If neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary death beneficiary. If any primary or contingent death beneficiary dies before me, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining death beneficiary shall be increased on a pro rata basis. If more than one primary death beneficiary is designated and no distribution percentages are indicated, the death beneficiaries will be deemed to own equal share percentages in the HSA. Multiple contingent death beneficiaries with no share percentage indicated will also be deemed to share equally. If no primary death beneficiary survives me, the contingent death beneficiary shall acquire the designated share of my HSA.

I understand that if I am married and my residence is in a community or marital property state, or if I am transferring property to this HSA that I acquired while married and residing in a community or marital property state, my spouse may have a community or marital property interest in contributions to and earnings in this HSA, whatever the source. This community property interest may be released by a properly executed consent. I understand that I may wish to consult with legal counsel to ensure that my designation is proper. I understand that if I designate my spouse as primary death beneficiary or contingent death beneficiary of the HSA, the dissolution, termination, annulment or other legal termination of my marriage will automatically revoke such designation. ___________________________________________________________ ___________________________________________________________ Signature of HSA Accountholder Date

Last Name: First Name: Middle Initial: Social Security Number: Employee ID and Employer if applicable: Telephone Number: Email Address: Primary: OffContingent: OffPrimary_2: OffContingent_2: OffPrimary_3: OffContingent_3: OffSpouse: OffDependent: OffOther: OffSpouse_2: OffDependent_2: OffOther_2: OffSpouse_3: OffDependent_3: OffOther_3: OffText1: Text2: Text3: Text4: Text5: Text6: Text7: Text8: Text9: Text10: Text11: Text12: Check Box13: OffCheck Box14: OffText15: 1-888-401-3539Text16: PO Box 1300, Manchester, NH 03105-1300Text17: Benefit Strategies LLC (TPA) at:

HSA-Brochure.pdf

HEALTH SAVING ACCOUNTSA Health Savings Account, or HSA, is a medical savings account that lets you pay for out-of-pocket healthcare expenses with pre-tax dollars if you are enrolled in a HSA qualified High Deductible Health Plan (HDHP). An HSA offers you a triple tax advantage, as well as a method to save for future healthcare expenses.

What is an HSA?An HSA is an individual account, fully owned by the account holder in the same manner as a personal bank account. Once funds are contributed, whether by you, your employer, or anyone else, you become the owner of the funds in your HSA immediately. Any interest or earnings on your HSA funds are yours. The money in your account remains yours even if you are no longer employed by your current employer and it remains in the account until you spend it – there is no deadline to spend these funds.

Funds contributed to an HSA have a triple tax advantage: 1. Contributions to your HSA are tax free 2. Interest and investment earnings grow tax free 3. Payments from your HSA for qualified medical expenses are tax free

Most of our participants save $27 in taxes for every $100 they contribute to their HSA.

TAXATION OF HSA FUNDS SPENT OR WITHDRAWNWhen you are under age 65:

Using your funds for HSA qualified healthcare expenses – distributions are tax free.Using your funds for non-HSA qualified healthcare expenses – distributions are subject to federal income tax andcurrently a 20% tax penalty applies.

When you are age 65 and older:Using your funds for HSA qualified healthcare expenses – distributions are tax freeUsing your funds for non-HSA qualified healthcare expenses – distributions are subject to federal income tax; no tax penalty applies.

IRS tax forms you will receive: 1099-SA: This provides you with the distributions from your HSA during the tax year, and is used to complete IRS form 8889.IRS Form 5498-SA: This provides you with the contributions made to your HSA during the tax year, and is used to complete IRS form 8889.

IRS tax forms to complete: IRS Form 8889: This is used to report HSA contributions, distributions and your tax deductions. You will file this form with your federal income tax form.

HSA ACCOUNT RESOURCESYour online account at www.benstrat.com

Through your secure online account you can view your account balance and account history, as well as request a distribution from your HSA account to be paid to you, or to a provider (check fee may apply). To login to your account:

• Go to www.benstrat.com• Login or follow the New User link to set up your User Name and Password

The Benefit Strategies mobile applicationDownload the Benefit Strategies mobile application for iPhone, Android, and tablet devices to access account information on the go!

Benefit Strategies Customer Relations Team, located in Manchester, NHOur Customer Service Representatives are available:Monday - Thursday 8:00 AM - 6:00 PM and Friday 8:00 AM - 5:00 PM (Eastern Time) • Telephone: 888-401-FLEX (3539); language translators are available• Online chat at www.benstrat.com• Email: info@benstrat.com.

Trust Loyalty Commitment• Our customers trust we are

committed to solving their problems.

Think Like the Customer• Treat others as you would like

to be treated.

Tender Loving Care• Attending to customers with con-

sideration and compassion – we strive for one-call resolution.

Eligibility to make and receive contributions to an HSAHSA contributions can only be made if you are enrolled in an HSA-compliant HDHP. Additional eligibility requirements are:

• You must be a United States resident and work and pay taxes in the U.S.

• You cannot be enrolled under a non-HSA compliant health plan.

• You cannot be enrolled in a regular Health FSA. (However, enrollment in

a Limited Purpose FSA for vision and dental expenses only is permitted).

• If you are married, your spouse cannot be enrolled in a Health FSA, but

his/her enrollment in a Limited Purpose FSA is permitted.

• You cannot be able to be claimed as a dependent on someone else’s tax

return.

• You cannot be enrolled in Medicare*.

How to open your HSA

Once your HSA enrollment is processed by Benefit Strategies, your enrollment information will be forwarded to our banking partner, Healthcare Bank (member FDIC), to establish your account. Healthcare Bank is a division of Bell State Bank, one of the Midwest’s largest banks. Benefit Strategies HSA administration is fully integrated with your account at Healthcare Bank. You will have convenient and secure account access through your personal login at www.benstrat.com and through our mobile application.

Making Contributions and the IRS 2016 Contribution MaximumsYou and anyone else can make contributions to your HSA, but you need to stay within the annual contribution maximums established by the IRS. Your contribution can be made through payroll deduction on a pre-tax basis where employees receive the tax advantage when filing their taxes.

* There are typically triggers that result in automatic enrollment in Medicare Part A (such as turning 65, or beginning to draw Social Security benefits). If you are within 6 months of either of these events, consult with the Social Security Administration on Part A enrollment and the effective date of coverage as it will impact your eligibility to make contributions to an HSA (although it won’t impact saving or spendig previously contributed HSA funds).

Investment of HSA Funds:HSA funds are held in an interest bearing cash account. You can choose to invest funds once your balance meets the minimum investment threshold. Your investment earnings, like interest earned on your HSA funds, grows tax free! Visit www.benstrat.com and click on the HSA link under the Employees/Participants tab to view current investment options available through Healthcare Bank.

USING YOUR HSA FUNDSAlthough there are regulations governing when contributions can be made to your HSA, there are no regulations gov-erning when you can use your HSA funds. Because the funds in your HSA are owned by you, they can be used at any time.

You can pay for qualified healthcare expenses by:

• Using your debit card, which will be sent to you once you open your account.

• Or you may pay for expenses yourself and request a distribution, which will be direct deposited into a bank account that you indicate when you open your HSA.

• You may also request a distribution payment be made via check directly to a provider (check fee may apply).

• Be sure to keep your receipts for qualified medical expenses the same as you do other important tax documents.

Funds held in the cash account are available immediately when you swipe your card or request a distribution. For invested funds, you will need to request a distribution from Benefit Strategies through your secure online account. Typical turn-around time for disbursements from invested funds is 5-7 business days.

Qualified HSA Expenses:Qualified expenses include the out-of-pocket expenses you incur under your employer’s HDHP, plus many other

medical, dental and vision expenses. You can even use HSA funds to pay for many medical plan premiums in

retirement.

HSA funds can be used to pay for qualified expenses for yourself, your legally married spouse and your tax dependents.

Eligibility to make and receive contributions to an HSAHSA contributions can only be made if you are enrolled in an HSA-compliant HDHP. Additional eligibility requirements are:

• You must be a United States resident and work and pay taxes in the U.S.

• You cannot be enrolled under a non-HSA compliant health plan.

• You cannot be enrolled in a regular Health FSA. (However, enrollment in

a Limited Purpose FSA for vision and dental expenses only is permitted).

• If you are married, your spouse cannot be enrolled in a Health FSA, but

his/her enrollment in a Limited Purpose FSA is permitted.

• You cannot be able to be claimed as a dependent on someone else’s tax

return.

• You cannot be enrolled in Medicare*.

How to open your HSA

Once your HSA enrollment is processed by Benefit Strategies, your enrollment information will be forwarded to our banking partner, Healthcare Bank (member FDIC), to establish your account. Healthcare Bank is a division of Bell State Bank, one of the Midwest’s largest banks. Benefit Strategies HSA administration is fully integrated with your account at Healthcare Bank. You will have convenient and secure account access through your personal login at www.benstrat.com and through our mobile application.

Making Contributions and the IRS 2016 Contribution MaximumsYou and anyone else can make contributions to your HSA, but you need to stay within the annual contribution maximums established by the IRS. Your contribution can be made through payroll deduction on a pre-tax basis where employees receive the tax advantage when filing their taxes.

* There are typically triggers that result in automatic enrollment in Medicare Part A (such as turning 65, or beginning to draw Social Security benefits). If you are within 6 months of either of these events, consult with the Social Security Administration on Part A enrollment and the effective date of coverage as it will impact your eligibility to make contributions to an HSA (although it won’t impact saving or spendig previously contributed HSA funds).

Investment of HSA Funds:HSA funds are held in an interest bearing cash account. You can choose to invest funds once your balance meets the minimum investment threshold. Your investment earnings, like interest earned on your HSA funds, grows tax free! Visit www.benstrat.com and click on the HSA link under the Employees/Participants tab to view current investment options available through Healthcare Bank.

USING YOUR HSA FUNDSAlthough there are regulations governing when contributions can be made to your HSA, there are no regulations gov-erning when you can use your HSA funds. Because the funds in your HSA are owned by you, they can be used at any time.

You can pay for qualified healthcare expenses by:

• Using your debit card, which will be sent to you once you open your account.

• Or you may pay for expenses yourself and request a distribution, which will be direct deposited into a bank account that you indicate when you open your HSA.

• You may also request a distribution payment be made via check directly to a provider (check fee may apply).

• Be sure to keep your receipts for qualified medical expenses the same as you do other important tax documents.

Funds held in the cash account are available immediately when you swipe your card or request a distribution. For invested funds, you will need to request a distribution from Benefit Strategies through your secure online account. Typical turn-around time for disbursements from invested funds is 5-7 business days.

Qualified HSA Expenses:Qualified expenses include the out-of-pocket expenses you incur under your employer’s HDHP, plus many other

medical, dental and vision expenses. You can even use HSA funds to pay for many medical plan premiums in

retirement.

HSA funds can be used to pay for qualified expenses for yourself, your legally married spouse and your tax dependents.

HEALTH SAVING ACCOUNTSA Health Savings Account, or HSA, is a medical savings account that lets you pay for out-of-pocket healthcare expenses with pre-tax dollars if you are enrolled in a HSA qualified High Deductible Health Plan (HDHP). An HSA offers you a triple tax advantage, as well as a method to save for future healthcare expenses.

What is an HSA?An HSA is an individual account, fully owned by the account holder in the same manner as a personal bank account. Once funds are contributed, whether by you, your employer, or anyone else, you become the owner of the funds in your HSA immediately. Any interest or earnings on your HSA funds are yours. The money in your account remains yours even if you are no longer employed by your current employer and it remains in the account until you spend it – there is no deadline to spend these funds.

Funds contributed to an HSA have a triple tax advantage: 1. Contributions to your HSA are tax free 2. Interest and investment earnings grow tax free 3. Payments from your HSA for qualified medical expenses are tax free

Most of our participants save $27 in taxes for every $100 they contribute to their HSA.

TAXATION OF HSA FUNDS SPENT OR WITHDRAWNWhen you are under age 65:

Using your funds for HSA qualified healthcare expenses – distributions are tax free.Using your funds for non-HSA qualified healthcare expenses – distributions are subject to federal income tax andcurrently a 20% tax penalty applies.

When you are age 65 and older:Using your funds for HSA qualified healthcare expenses – distributions are tax freeUsing your funds for non-HSA qualified healthcare expenses – distributions are subject to federal income tax; no tax penalty applies.

IRS tax forms you will receive: 1099-SA: This provides you with the distributions from your HSA during the tax year, and is used to complete IRS form 8889.IRS Form 5498-SA: This provides you with the contributions made to your HSA during the tax year, and is used to complete IRS form 8889.

IRS tax forms to complete: IRS Form 8889: This is used to report HSA contributions, distributions and your tax deductions. You will file this form with your federal income tax form.

HSA ACCOUNT RESOURCESYour online account at www.benstrat.com

Through your secure online account you can view your account balance and account history, as well as request a distribution from your HSA account to be paid to you, or to a provider (check fee may apply). To login to your account:

• Go to www.benstrat.com• Login or follow the New User link to set up your User Name and Password

The Benefit Strategies mobile applicationDownload the Benefit Strategies mobile application for iPhone, Android, and tablet devices to access account information on the go!

Benefit Strategies Customer Relations Team, located in Manchester, NHOur Customer Service Representatives are available:Monday - Thursday 8:00 AM - 6:00 PM and Friday 8:00 AM - 5:00 PM (Eastern Time) • Telephone: 888-401-FLEX (3539); language translators are available• Online chat at www.benstrat.com• Email: info@benstrat.com.

Trust Loyalty Commitment• Our customers trust we are

committed to solving their problems.

Think Like the Customer• Treat others as you would like

to be treated.

Tender Loving Care• Attending to customers with con-

sideration and compassion – we strive for one-call resolution.

HSA-Investment-Options.pdf

Category

HealthcareBank Interest Bearing Account Cash EquivalentFDIC Insured - Bank Guaranteed

Category Symbol YTD3 Year

Return

5 Year

Return

10 Year

Return

Expense

Ratio

Conservative Allocation GLRBX P M -1.84% 4.27% 5.65% 5.86% 0.97

Moderate Allocation PACLX P M -2.58% 10.03% 9.52% 7.64% 1.01

World Allocation WASAX P M -5.33% -0.45% 1.94% 6.01% 0.96

Large Blend VFINX P M -5.11% 10.58% 9.97% 6.32% 0.17

Large Growth GFAFX P M -8.50% 10.26% 8.97% 5.99% 0.70

Mid-Cap Blend VIMSX P M -6.34% 9.39% 8.57% 6.59% 0.23

Mid-Cap Blend OMEAX P M -5.25% 8.84% 8.44% 6.56% 0.97

Mid-Cap Growth NMGAX P M -9.74% 6.77% 7.14% 6.33% 1.12

Small Blend NAESX P M -6.81% 7.13% 7.43% 6.26% 0.23

Small Growth VISGX P M -8.98% 5.84% 6.51% 6.37% 0.23

Small Value NOSGX P M -4.82% 7.23% 7.39% 5.47% 1.23

Foreign Large Blend VGTSX P M -7.73% -1.61% -1.05% 1.40% 0.19

Foreign Large Growth AEGFX P M -8.84% 1.09% 1.11% 3.11% 0.86

International FDVAX P M -8.32% 4.29% 2.86% 1.44% 1.22

Diversified Emerging Mkts VEIEX P M -6.82% -8.81% -5.61% 1.55% 0.33

World Stock VTWSX P M -6.61% 3.91% 3.84% - 0.25

Real Estate FREAX P M -4.63% 7.72% 8.91% 6.99% 1.30

World Bond TPINX P M -3.79% -1.84% 1.43% 6.44% 0.91

Intermediate-Term Bond VBIIX P M 2.92% 2.38% 4.81% 5.71% 0.20

Intermediate-Term Bond PTRAX P M 0.30% 0.90% 3.17% 5.48% 0.71

Core Bond VBMFX P M 2.10% 1.97% 3.39% 4.55% 0.20

Resource Links :: P - Prospectus, M - Morningstar®

Fidelity Advisor Diversified International

Annual Percentage

Rate

0.20%

Annual

Percentage Yield

(APY)

0.20%

Resource

Links

HSA Investment Options

Vanguard Small Cap Growth Index (Inv)*

James Balanced Golden Rainbow (Retail)*

Northern Small Cap Value*

INTEREST BEARING OPTIONFund Name

Rate Effective

June 1, 2012

MUTUAL FUND OPTIONSFund Name

Mutual Fund Returns as of February 29, 2016

TRowe Price Capital Appreciation Fund (Adv)*

Ivy Asset Strategy (A)*

Vanguard 500 Index (Inv)*

*The bank acts solely as custodian with any mutual funds being offered and sold through a registered broker-dealer by prospectus only. Past performance of investments is no indication or assurance of future

performance. As with all investments, mutual funds involve risk. The investment return and principal value will fluctuate so that shares, when redeemed, may be worth more or less than their original cost. Read

the prospectus carefully before you invest. Some funds have a redemption fee under certain circumstances.

Not FDIC Insured - No Bank Guarantee - May Lose Value

American Funds Growth Fund of America (F1)*

Neuberger Berman MidCap Growth

Vanguard Total International Stock Index (Inv)*

Vanguard Small Cap Blend Index (Inv)*

American Funds Europacific Growth (F1)*

Vanguard Mid Cap Index (Inv)*

JPMorgan Market Expansion Index (A)*

Vanguard Emerging Market Stock Index (Inv)*

Vanguard Total World Stock Index (Inv)*

Nuveen Real Estate Securities (A)*

Templeton Global Bond (A)*

Vanguard Intermediate Term Bond Index (Inv)*

PIMCO Total Return (Adm)*

Vanguard Total Bond Market Index (Inv)*

https://hsainvestments.com/fundlink/?p=HCB&ps=GLRBX

https://hsainvestments.com/fundlink/?p=HCB&ms=GLRBX

http://individual.troweprice.com/gcFiles/pdf/trcaf.pdf

https://hsainvestments.com/fundlink/?p=HCB&ms=PACLX

https://hsainvestments.com/fundlink/?p=HCB&ps=WASAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ms=WASAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ps=VFINX

https://hsainvestments.com/fundlink/?p=HCB&ms=VFINX

https://hsainvestments.com/fundlink/?p=HCB&ps=GFAFX

https://hsainvestments.com/fundlink/?p=HCB&ms=GFAFX

https://hsainvestments.com/fundlink/?p=HCB&ps=VIMSX

https://hsainvestments.com/fundlink/?p=HCB&ms=VIMSX

https://hsainvestments.com/fundlink/?p=HCB&ps=OMEAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ms=OMEAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ps=NMGAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ms=NMGAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ps=NAESX

https://hsainvestments.com/fundlink/?p=HCB&ms=NAESX

https://hsainvestments.com/fundlink/?p=HCB&ps=VISGX

https://hsainvestments.com/fundlink/?p=HCB&ms=VISGX

https://hsainvestments.com/fundlink/?p=HCB&ps=NOSGX

https://hsainvestments.com/fundlink/?p=HCB&ms=NOSGX

https://hsainvestments.com/fundlink/?p=HCB&ps=VGTSX

https://hsainvestments.com/fundlink/?p=HCB&ms=VGTSX

https://hsainvestments.com/fundlink/?p=HCB&ps=AEGFX

https://hsainvestments.com/fundlink/?p=HCB&ms=AEGFX

https://hsainvestments.com/fundlink/?p=HCB&ps=FDVAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ms=FDVAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ps=VEIEX

https://hsainvestments.com/fundlink/?p=HCB&ms=VEIEX

https://hsainvestments.com/fundlink/?p=HCB&ps=VTWSX

https://hsainvestments.com/fundlink/?p=HCB&ms=VTWSX

https://hsainvestments.com/fundlink/?p=HCB&ps=FREAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ms=FREAX.LW

https://hsainvestments.com/fundlink/?p=HCB&ps=TPINX.LW

https://hsainvestments.com/fundlink/?p=HCB&ms=TPINX.LW

https://hsainvestments.com/fundlink/?p=HCB&ps=VBIIX

https://hsainvestments.com/fundlink/?p=HCB&ms=VBIIX

https://hsainvestments.com/fundlink/?p=HCB&ps=PTRAX

https://hsainvestments.com/fundlink/?p=HCB&ms=PTRAX

https://hsainvestments.com/fundlink/?p=HCB&ps=VBMFX

https://hsainvestments.com/fundlink/?p=HCB&ms=VBMFX

HSA Account Detail

Report Sample.xls

HSA Account Detail Report (DetadivisionidentifierlastNamefirstNameaccountNumberamountcontribTypetaxYearprocessedDatenoteDivision 112345AppleAustin$93.75Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 112345AppleAustin$93.75Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 164789BrownChris$187.50Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 164789BrownChris$187.50Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$93.75Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$128.85Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 1741852CampbellJames$93.75Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$93.75Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer ContributionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$11.54Payroll Deduction20XXDD/MM/YYYYDD/MM/YYYY Payroll DeductionDivision 2963852DayMark$93.75Employer Contribution20XXDD/MM/YYYYDD/MM/YYYY Employer Contribution

HSA Employer Summary Report Sample.pdf

HSA EFT Funding

Agreement - Contributions & Admin Fees.pdf

Health Savings Account (HSA) EFT Debit Agreement

HSA Funding and Administrative Fees require EFT Debit of the bank account(s) you indicate on this form by our banking partner, Healthcare Bank.

Client Name:

HSA Contributions Funding Client must upload a contribution file each pay period through client’s secure online portal at benstrat.com. Upload triggers an EFT debit of the bank account indicated below. Within 2 business days of the EFT debit, Healthcare Bank will have completed distribution of the funds to each participant’s Health Savings Account. Claims Funding Contact Name:

Title:

Phone Number: Email:

Bank Routing #: Bank Account #:

Account Type: □ Checking □ Savings

Bank Name: Bank City and State:

Administrative Fees - Includes set-up, renewal and administrative fees Invoiced quarterly in advance. Emailed invoice sent 2 business days prior to automatic EFT debit of the bank account you indicate below.

□ Contact information is same as above. (If not, complete below)

□ Banking information is same as above. (If not, complete below) Admin Fees Contact Name:

Title:

Phone Number: Email:

Bank Routing #: Bank Account #:

Account Type: □ Checking □ Savings

Bank Name: Bank City and State:

Authorized Signer

Authorized Signer Name: Title:

Email: Phone:

Authorized Signature: Date: