Please take a minute to fill out the information below. This will allow us to generate the paperwork for your HEALTH SAVINGS ACCOUNT. Please be sure to complete all fields. Thank you for choosing CenterState Bank.

Primary Account Holder











(required for Online Banking)











Issue Date *
Exp. Date *
Is your policy *
Authorized Signer











(required for Online Banking)











Issue Date
Exp. Date
An Electronic Monthly Statement is provided through your Free Online Banking. Will you be using Online Banking? *
*Please provide us with a User ID to enroll you in our Online Banking

(8-20 letters and/or numbers with no special characters)

Designation of Beneficiary

Primary Beneficiary
1

%



2

%



3

%



Contingent Beneficiary
1

%



2

%



3

%



Please remember to provide us with proof of physical address if your current address is not listed on your driver’s license. Items such as a utility bill, auto insurance card, lease/rental agreement, etc. may be used as proof.