State of WI Employee Enrollment Form - …

Health Savings Account (HSA) State of WI Employee Enrollment form Items Included: Enrollment form (p. 1) Privacy Policy (pp. 4-5) Terms, Conditions, and Signature optional checkbox and signature Custodial Agreement and Disclosure Statement (pp. 8-19) Designation of Representative by Accountholder (pp. 19-22) Employee /PARTICIPANT INFORMATION Last Name: _____ First Name: _____ Middle Initial: _____ Employee ID# (if known): _____ Social Security Number: _____ Date of Birth (mm/dd/yyyy): _____ Mother Maiden Name: _____ Gender: Female Male Marital Status: Single Married Daytime Phone Number: _____ Email Address: _____ Home Address (street): _____ City: _____ State : _____ Zip Code: _____ Employer Name (select one): Central Courts FRNSA Legislature UW Hospitals & Clinics UW System WEDC WHEDA Wiscraft Beyond Vision Date of Hire: Hours Worked per Week: Payroll Frequency: First Payroll Date: Participant Plan Effective Date: ANNUAL ELECTIONS I am enrolling in an HSA through my employer.

Health Savings Account (HSA) TASC Customer Care | Phone 844-786-3947 or 608-316-2408 | Email 1customercare@tasconline.com Page 1 SW-5514-042617 State of WI Employee Enrollment Form

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