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 First Name * Middle Initial * Last Name * Social Security Number * Street Address * Birth Date * City * State * Zip Code * E-Mail Address * (required for Online Banking) Mailing Address (if different from Street Address) * Work Phone # * City * State * Zip Code * Cell # or Home Phone # * Employer * Occupation/Title * Mother’s Maiden Name * Drivers License # * DL State * Issue Date * MonthJanFebMarAprMayJunJulAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year200220032004200520062007200820092010201120122013201420152016 Exp. Date * MonthJanFebMarAprMayJunJulAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year201220132014201520162017201820192020202120222023202420252026202720282029 Is your policy * Self Family* Authorized Signer First Name Middle Initial Last Name Social Security Number Street Address Birth Date City State Zip Code E-Mail Address (required for Online Banking) Mailing Address (if different from Street Address) Work Phone # City State Zip Code Cell # or Home Phone # Employer Occupation/Title Mother’s Maiden Name Drivers License # DL State Issue Date MonthJanFebMarAprMayJunJulAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year200220032004200520062007200820092010201120122013201420152016 Exp. Date MonthJanFebMarAprMayJunJulAugSepOctNovDecDay12345678910111213141516171819202122232425262728293031Year201220132014201520162017201820192020202120222023202420252026202720282029 An Electronic Monthly Statement is provided through your Free Online Banking. Will you be using Online Banking? * Yes* No *Please provide us with a User ID to enroll you in our Online Banking User ID (8-20 letters and/or numbers with no special characters) Designation of Beneficiary Primary Beneficiary 1 Percentage % Name of Beneficiary Relationship to HSA Owner SSN or Tax ID Number 2 Percentage % Name of Beneficiary Relationship to HSA Owner SSN or Tax ID Number 3 Percentage % Name of Beneficiary Relationship to HSA Owner SSN or Tax ID Number Contingent Beneficiary 1 Percentage % Name of Beneficiary Relationship to HSA Owner SSN or Tax ID Number 2 Percentage % Name of Beneficiary Relationship to HSA Owner SSN or Tax ID Number 3 Percentage % Name of Beneficiary Relationship to HSA Owner SSN or Tax ID Number 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.
