First Name Last Name

Address

StateCity Zip

Employer Sign-Up Form(Starmark Groups)

FORM_ERSignUp_Starmark_1107

Instructions: (Be sure that you have completed Starmark’s Custodian Election Form and that you have been assigned agroup number prior to completing this form.) Only complete the Agent Identification Number (AIN) field below if you areworking with an agent who is registered with HSA Bank. All other fields are required. Fax this signed & completed formto Business Relations: (920) 803-4184. If you have questions, please call (866) 357-5232, M - F, 7 a.m. - 7 p.m. CST.

Company Information

Company Name

Federal Tax ID #

Business TypeSole ProprietorCorporation

LLCNon-Profit

PartnershipJoint VentureTrust Association/Cooperative Other____________________

Phone - - Fax - -

Main Administrator Information

Email

Select User Name(min. 8 characters)

(letters and numbers only)

A random password will be assigned and emailed to you. You will be asked to change this password the firsttime you log into the Employer Site.

Important note: The Main Administrator is the only individual that will have full administrative rights. This meansthat only they will have the ability to add other administrative users and assign rights for accessing or updating youraccount.

HSA Bank’s Employer Site is designed to help you manage your employees who have accounts with HSA Bank. At thissite, employers will be able to manage their HSA programs, receive updates regarding HSA Bank, and access updatesregarding IRS Rulings. There is also an option to make contributions to employees’ accounts through this site using theonline contributions tool. A welcome kit will be emailed to you with a separate form to sign up for this option.

Extension

HealthPlanAINStarmark

Group #

RESOLUTIONS AUTHORIZING SIGNERSThe Authorized Representative is/are (the singular shall include the plural):

ADOPTION OF RESOLUTIONS: Employer/Business Partner, acting herein by the undersigned Authorized Representative (Section2) does hereby adopt the Resolutions set forth below, and certify that such resolutions are in accordance and conformity with theEmployer's governing documents, all agreements with third parties, and all laws applicable to the Employer.

The undersigned Authorized Representative (Section 2) is duly authorized to execute the resolutions herein on behalf of Employer andto complete all information in said resolutions. The undersigned Authorized Representative (Section 2) certifies on behalf of theEmployer that the following Main Administrator (Section 1) is empowered to act alone for and on behalf of the Employer Partner withrespect to the Employer website, which shall contain confidential employee information, and to agree on the Employer’s behalf toterms and conditions for the use of the Employer site:

Section 1: Main Administrator Signature

The Bank may rely on the accuracy of the foregoing certification until the Bank has actually received written notice of a change andhas had a reasonable period of time to act on such notice.

The undersigned Authorized Representative (Section 2) agree(s) to notify the Bank promptly and in writing of the happening of anychange in the identity of officers, members, managers or partners of the Employer or in the ownership of the Employer or in theEmployer's legal structure and of the happening of any dissolution or bankruptcy of the Employer or of any partner, manager, memberor owner of the Employer.

CERTIFICATION OF RESOLUTIONS: The undersigned Authorized Representative (Section 2) is authorized by the Employer tocertify, and hereby does certify, that the resolutions set forth above were properly adopted on the _____ day of__________ , 20_____by the Employer. In accordance and conformity with the Employer's governing documents, all agreements with third parties, and alllaws applicable to the Employer, have not been modified or rescinded, and are in full force and effect and binding on the Employer.

IN WITNESS WHEREOF, I/We have signed this certificate as duly Authorized Representative(s) of Employer; Employer validlyexists and is in good standing under applicable law, and that the name of the Employer identified herein is accurate and complete atthis date, the _____day of__________, 20_____ .

Section 2: Authorized Representative Signature

NOTE: THE PERSON SIGNING AS THE MAIN ADMINISTRATOR IN SECTION 1 MUST BE DIFFERENT THAN THEAUTHORIZED REPRESENTATIVE SIGNER IN SECTION 2, UNLESS THE EMPLOYER IS A SOLE PROPRIETOR.

Privacy, the USA PATRIOT Act, and the Employer SiteAt HSA Bank we respect and protect the confidentiality of customer information. Some of the information we request is required by aFederal law called the USA PATRIOT Act and regulations adopted by governmental agencies to implement it. This law requires HSABank to obtain, verify and record information that identifies each person or entity that opens an account. This information helps thegovernment fight the funding of terrorism and money laundering activities. When you sign up for the Employer Site, we will ask youfor your company’s name and address. We will also ask you for an identification number such as your Social Security, EIN or TaxIdentification number. This information will allow us to identify you. In some instances we may also ask to see identifying documents.Please rest assured that all customer information is kept in the strictest confidence, unless required by law to be disclosed.

the Employer (Sole Proprietor)

a/the (Specify Title) ____________________________________of the Corporation/Municipality/Other (circle one)

The general partners (Partnership) Managers (LLC) Members of the Employer (LLC)

Name (please print) Title Signature

FORM_ERSignUp_Starmark_1107

Name (please print) Title Authorized Signature

Name (please print) Title Authorized Signature

HSA Bank® is a division of Webster Bank, N.A., Member FDIC

1969074062

HSA Bank offers you:

• Simple ways to contribute

• Easy online management

• Industry leading customer support

www.hsabank.com/getstarted

We get HSAs right.So you can focus on your health.

It’s your health. Manage it with a Health Savings Account

(HSA). A Health Savings Account (HSA) is a special account where

you save money, tax-free, to cover certain healthcare costs. It works

with an HSA-compatible health plan. With contributions that grow

and earn interest over time, an HSA is to healthcare what a 401K is

to retirement. And with balances that rollover year-to-year, you’ll have

constant access to your HSA funds and you’ll never lose the money.

HSA-compatible health plan. To sign up for an HSA, you

must be enrolled in an HSA-compatible health plan.

• Lower premium, higher deductible

• Prescription drug costs count towards the max out-of-pocket

• Expenses after max out-of-pocket are covered at 100%

To determine if your current health plan is HSA-compatible,

contact your health plan provider.

We build your HSA around you. And confi dence is built in.

We’re a leader in the HSA industry because the first thing we do

is help you to understand how your HSA can best benefit you and

your family. We’ve been working this way since HSAs were first

offered in 1997. You can feel safe and secure, knowing we take

your healthcare needs to heart and we have the experience and

expertise to serve you right.

Managing your account is easy. With 24-hour access to Internet

Banking, you can choose how you want to transfer funds, review

statements and account balances, initiate transfers, and access

year-to-date information and tax documents. You can also take

“ Like a 401K for your healthcare, except you

can use your HSA money whenever you need to

for medical expenses.”

HSA: Savings for your healthcare

• Pre-tax contributions

• Fund roll-over

• Investment options

Just a few ways to use your HSA:

• Deductibles

• Co-insurance

• Eye-glasses

• Prescriptions

Is an HSA right for you? Find out at www.hsabank.com/getstarted

• Learn more about HSAs

• Calculate your potential premium and tax savings

• Forecast your savings’ future value

• Receive a recommendation based on your lifestyle

• Decide if an HSA is the right way to go

advantage of toll-free phone banking or speak live with a specialist

about your account. If you happen to have a question after business

hours, our dedicated customer service department will give you a

response in 24-hours or less.

Contributing is simple. We have several easy ways to put

money into your HSA. Whichever method you choose, you can

start contributing in as little as two days.

• Schedule transfers to or from your bank account

through Internet Banking

• Make contributions through payroll deductions

• Send a check with a contribution form or deposit ticket

• Track your contributions online

Using your money is even simpler. Pay medical expenses

or withdraw cash from an ATM with your HSA Bank Visa® debit

card. You can also buy HSA Bank checks or pay medical

expenses from your bank account and reimburse yourself

through Internet Banking.

Growing your savings tax-free. Your contributions

will grow tax-free in your HSA. And if you’d like to

invest your HSA dollars, you can do so through our

investment partners, who offer stocks, bonds and

mutual funds.

Investment accounts are not FDIC insured, may lose value and are not a deposit or other obligation of, or guarantee by the bank. Investment losses which are replaced are subject to the annual contribution limits of the HSA.

* Based on 2009 actuals.

You can use your HSA dollars to pay for healthcare services and equipment, as well as dental, vision, prescription, and chiropractic costs.

Go to www.hsabank.com/getstarted for a complete list of eligible medical expenses.

Eligible Expenses: What to expect.

“ We answer calls

in an average of

13 seconds.”*

“ Our customers

are 22% more

satisfi ed than the

industry average.”

START SAVING TODAY -

3 EASY STEPS

1

Here are a few things to keep in mind:• Be sure all network discounts are applied before making a payment.

Usually you’ll need to wait for an Explanation of Benefi ts (EOB) from

your health plan.

• HSAs have a low-premium, high deductible structure, making the

payment process different from traditional health plans. If you are

required to make a payment at the time of service, but have not had

a chance to build your HSA funds, consider the following options:

1. Pay your entire bill with another payment method, like your bank

account. Or split up the cost by making a partial payment from

your HSA.

2. Contact your healthcare provider and request a payment plan.

For large expenses, healthcare providers will generally provide

low interest payment plans.

3. No matter what payment method you choose, you can accumulate

HSA funds over time and pay yourself back when you are ready.

• Payments made for prescriptions count towards your maximum

out-of-pocket expenses. Once you reach your maximum,

prescriptions will be covered 100%.

• For out-of-network or large expenses, consider using a claims

negotiation service to assist in reducing your bill.

Visit www.hsabank.com for more information.

Your responsibility. Keeping yourself informed will help make the most of your

HSA and get the care you deserve.

• Your physician can help discuss alternatives

• Price shop to ensure the best value

• Empower yourself, utilizing resources online and

through your health plan

• Protect your savings by staying healthy and keeping active

• Finding prescription drug options can save you money

Verify you are eligible.

You must be covered under an HSA-

compatible health plan, not be enrolled

in Medicare or other non-compatible plans,

and not be claimed as a dependent on

another person’s tax return.

2 Complete the HSA

application.

If you are signing up through your

employer, they will provide you with

an enrollment link or application.

Otherwise, complete our Individual

Online Enrollment form at

www.hsabank.com/getstarted.

Start saving.

Your account is typically opened

within 1-2 business days and you

can expect your Welcome Kit and

debit cards to arrive 7-10 days later.

To sign up for Internet Banking access

and for electronic statements, visit:

https://secure.hsabank.com/ibanking.

3

(800) 357-6246 Monday – Friday, 7 a.m. – 9 p.m., CT

www.hsabank.com

For assistance, please contact Client Assistance Center

605 N. 8th Street, Ste. 320, Sheboygan, WI 53081

2011 IRS Guidelines for HSA-compatible Health Plans and HSA Contribution Limits.

Individual Family

Minimum Deductible $1,200 $2,400

Maximum Out-of-Pocket $5,950 $11,900

Contribution Limit $3,050 $6,150

For those 55 and older, an extra $1,000 catch-up contribution can be added to the overall contribution limit.

IRS G id li f HSA ibl H l h Pl d HSA C ib i Li i

$400,000

$350,000

$300,000

$250,000

$200,000

$150,000

$100,000

$50,000

$00 5 10 15 20 25 30 35 40

YEARS

$512.50/month*

$400/month

$300/month

$254.16/month**

$200/month

$150/month

$100/month

$50/month

Save for today, tomorrow and beyond.

(800) 357-6246 Monday – Friday, 7 a.m. – 9 p.m., CTwww.hsabank.com

For assistance, please contact Client Assistance Center

605 N. 8th Street, Ste. 320, Sheboygan, WI 53081

Even a little goes a long way.

With a Health Savings Account (HSA), you

experience tax savings on contributions and

tax-deferred growth on the earnings. Whether you are

saving the maximum or only a portion each year, your

HSA dollars can grow. Think about what you could gain

over the years by saving even $100 or $200 a month.

Calculate your savings potential.

These examples demonstrate the potential for savings

and account growth. To calculate approximate savings

based on your specifi c circumstances, use our Future

Value calculator at: www.hsabank.com/calculators.

All figures are provided for illustration purposes only. Actual savings, tax rates and earnings may vary.*Family maximun**Individual maximum

Account Growth Potential Chart

An eligible expense is defi ned as an expense which pays for care as described in Section 213 (d) of the Internal Revenue Code. This list is not comprehensive, is meant to serve as a quick reference, and is provided to you with the understanding that HSA Bank is not engaged in rendering tax advice. The information provided is not intend-ed to be used to avoid federal tax penalties. For more detailed information, please refer to IRS Publication 502 titled, “Medical and Dental Expenses,” Catalog Number 15002Q. Publications can be ordered directly from the IRS by calling 1-800-TAXFORM. If tax advice is required, you should seek the services of a professional.

* Beginning in 2011, tax-free HSA funds no longer can be used to purchase over-the-counter drugs that are not prescribed by a doctor.

Health insurance may not be purchased with HSA funds. However, HSA funds can be used to pay for: 1) Health plan premiums during any period of continuation coverage required under any Federal (COBRA) 2) A qualifi ed long-term care insurance contract 3) A health plan during a period in which the individual is receiving unemployment compensation under any Federal or State Law 4) For individuals over age 65, premiums for Medicare Part A or B, a Medicare HMO and/or the employee share of premiums for employer-sponsored health

insurance, including premiums for employer-sponsored retiree health insurance

Your HSA covers a wide variety of medical costs. Below is a list of just some of the eligible expenses.

Eligible Medical Expenses.

ALTERNATIVE THERAPYAcupuncture

Chiropractor

Christian Science Practitioner

DENTALBraces

Dental treatment

Dental X-rays

Dentures

Fluoridation unit

Gum treatment

EYE AND EARContact lenses

Eyeglasses

Guide dog

Hearing aids and batteries

Ophthalmologist

Optician

Optometrist

Telephone or TV equipment

to assist the hard-of-hearing

EQUIPMENTAir conditioner (when

necessary for relief from

diffi culty in breathing)

Autoette (when used for relief of

sickness/disability)

Cardiograph

Oxygen and oxygen

equipment

Therapy equipment

FEES Ambulance

Diagnostic fees

Fees paid to health institute

prescribed by a doctor

FICA and FUTA tax paid for

medical care service

Hospital bills

Legal fees

Operating room costs

Special school costs for

the handicapped

Transportation expenses

GENERAL CARE

Dermatologist

Neurologist

Nursing

Orthopedist

Osteopath

Pediatrician

Physician

Podiatrist

LIVING EXPENSESConvalescent home (for medical

treatment only)

Lodging (away from home for

outpatient care)

MEDICINE*Prescription drugs and

medicines

MENTAL HEALTHPsychiatrist

Psychoanalyst

Psychologist

Psychotherapy

PREVENTIVELead paint removal

Vaccines

PROSTHETICSArtifi cial limbs

RECOVERY AIDSAbdominal supports

Arch supports

Crutches

Orthopedic shoes

Splints

Wheelchairs

REPRODUCTIONAbortion

Birth control pills

(by prescription)

Childbirth/Delivery

Contraceptive devices

(by prescription)

Gynecologist

Obstetrician

Prenatal care

Postnatal treatments

Sterilization

Vasectomy

SUBSTANCE ABUSE Alcoholism treatment

Drug addiction therapy

SURGERYAnesthetist

Oral surgery

Organ transplant (including

donor’s expenses)

Surgeon

TESTSBlood tests

Lab tests

Metabolism tests

Spinal fl uid test

X-Rays

THERAPYElastic hosiery

(by prescription)

Hydrotherapy

Physiotherapist

Radium therapy

TREATMENTBlood transfusions

Ultra-violet ray treatment

A

You Pay

B

C

D

E

F

G

You Pay

H

I

J

K

L

M -N

O

If G is greater than N, Subtract G__________ - N__________ This is the estimated amount you could save with the HSA Plan. If N is greater than G, the Non-HSA Plan may be the more economical choice. Additional factors not considered in this calculation include: tax savings on HSA contributions, tax savings on HSA earnings, and tax savings on distributions for qualified medical expenses.

Enter the amount your employer will contribute to your HSA and subtract from L

HSA-COMPATIBLE PLAN

Your Cost with the HSA-Compatible Plan

If J1 is greater than your HSA-compatible plan deductible, calculate HSA plan coinsurance. Otherwise enter 0.

1. J1 ________ - HSA-compatible plan deductible ________ = __________2. K1 _______ X % you pay after the deductible __________ =

Subtotal (Add H-K)

1. Number of Prescriptions_____X Average cost (if cost is unknown, enter $50)_______=_______

Calculate the amount applied to your HSA-compatible plan deductible.

1. Line A1_______ + Line I1 _____=________ This amount will be carried to lines J2 & K1.

NON-HSA PLAN

2. Non-HSA plan deductible=_______ D1=_______ Enter the lower of these two amounts

If D1 is greater than your non-HSA plan deductible, calculate non-HSA plan co-insurance. Otherwise enter 0.

1. D1 ________ - non-HSA plan deductible ________ = __________

2. COMPLETE IF NOT PAYING PRESCRIPTION CO-PAYS. This amount will be carried to line D1. # of Prescriptions_____X Average cost (if cost is unknown, enter $50)_______= _______

Calculate the amount applied to your non-HSA plan deductible.

Calculate your prescription costs under the non-HSA plan Complete 1 if paying co-pays and enter zero in C2. Complete 2 if not paying co-pays.

Non-HSA Plan vs. HSA-Compatible Plan Decision Worksheet

To use our electronic Is an HSA Right for Me? decision tool, please visit us online at: zixbypass

www.hsabank.com/calculators

Calculate your prescription costs under the HSA-compatible plan. This amount will be carried to line J1.

Instructions: Please complete the information below to the best of your knowledge. All amounts are estimates and are meant for illustrative purposes. Actual costs may vary.

Calculate the annual cost of Dr. visits. This amount will be carried to lines D1 & J1.1. Estimated # of Dr. visits _____ X Average cost/Dr. visit (if unknown, enter $150)_______ =_______

Amount you would pay in Non-HSA premiums/yr = cost/month_______X 12 months=

Amount you would pay in HSA-Compatible premiums/yr = cost/month_______X 12 months=

2. E1 _______ X % (as a decimal) you pay after the deductible __________ =

1. COMPLETE IF PAYING PRESCRIPTION CO-PAYS Amount Spent on prescription copays/yr.,Prescription copays/year_____X amt. of copay (If copay amount unknown, use $15)______=

1. Line A1______ + Line C2______ = _______ This amount will be carried to lines D2 & E1.

2. HSA-compatible plan deductible=_______ J1=_______ Enter the lower of these two amounts

Other anticipated out-of-pocket expenses (doctor or emergency room co-pays, etc.)

Your Cost with the Non-HSA Plan (Add B-F)

COL_DecisionWorksheet_976_072407_V.2.3

HSA Custodian Election Form

Complete this form to begin the process of establishing HSAs for your employees. Give your employees online HSA balance viewing by electing one of Starmark’s preferred HSA custodians. A) Check one box in this section:

Employer will provide direct financial assistance in setting up and/or funding employees’ HSAs. Please continue to Section B to choose a custodian and indicate the level of employer support. Then complete the contact information requested in Section C.

Employer will not provide direct financial assistance in setting up or funding employees’ HSAs. We understand that Starmark will not enable

online links or automated enrollment capabilities. When establishing an HSA, the employer and its employees will enroll with a custodian directly.

B) Choose one HSA custodian and level of financial support: The account holder will be charged these fees if the employer does not elect to pay them.

HSA Bank Employer intends to pay the following fees or enable indicated transactions (Check all that apply): Setup fee for electronic enrollment enabled by Trustmark (Pick one): Online enrollment via link from Starmark website to HSA Bank: $18 per account (up to two debit cards included) Paper enrollment: $25 per account (up to two debit cards included) Monthly maintenance fee ($2.25 per account, per month) Employer contribution or payroll deduction HSA Bank should contact employer at location below upon acceptance by Starmark.

Charles Schwab Trust Company, administered by Alliance Benefit Group of Illinois Employer intends to pay the following fees or enable indicated transactions (Check all that apply): Monthly maintenance fee ($4 per account, per month) Employer contribution or payroll deduction Schwab/ABG should contact employer at location below upon acceptance by Starmark. C) Employer’s administrative contact information for HSAs (Please provide all information): Legal Name of Company (Employer) Federal Employer Identification Number (FEIN) Street Address City State ZIP ( ) ( ) Employer Administrative Contact Telephone Number Fax Number E-mail Address Employer has online access: Yes No Employees have online access: Yes Some No

Please send this completed form to: Starmark E-mail: Account.Management@Starmarkinc.com 400 Field Drive Phone: 800.522.1246 ext. 35380 Lake Forest, IL 60045 Fax: 847.615.3813 Attn: Account Management For Starmark/Trustmark Life use only.

New employer, approved Existing group, (group No.: _____________________)

S669-114 (4-07)