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Print clearly. Your HSA is your financial asset even if you change employers or health plans. You must meet the requirements under Internal Revenue Code Section 223 to be eligible to open and contribute to an HSA. This means that:  \n1. You must be covered by a qualified high-deductible plan.  \n2. You cannot be covered by another health plan, including Medicare or Flexible Spending Account. (You may be covered by a Limited Use Flexible Spending Account or Limited Use Health Reimbursement Arrangement. )  \n3. You cannot be claimed as a dependent on another individual’s tax return.  \nConsult with your employer for more information about HSA eligibility requirements.  \nIf you are an active employee, return this completed form to your employer.  \nRetirees and survivors, return to: ETF Retiree Health Insurance Unit , P.O. Box 7931, Madison, WI 53707-7931 or fax: [1-608-226-5535 or email ](1-608-226-5535 or email RetireeHealth@etf.wi.gov)[RetireeHealth@etf.wi.gov](1-608-226-5535 or email RetireeHealth@etf.wi.gov).  \n\n| Section 1: Application Information Only the subscriber applying for coverage should complete this form. |  |  |  |  |\n| --- | --- | --- | --- | --- |\n| Name (first, middle, last, former/maiden) |  |  |  | Last 4 digits of SSN |\n| Birth date (MM/DD/YYYY) | Telephone , including area code | Email |  |  |\n| Address (Street , City, State, ZIP Code) Note: Must be a valid U. S. street address; P. O. Box may not be used |  |  |  |  |\n| If you are currently working-Employer name |  |  | If you are currently working-Employee ID |  |\n| Marital status\u003Cbr> Single  Married  Divorced  Widowed |  |  | Enrollment status\u003Cbr> New enrollment  Re-enrollment |  |\n\n\n| Section 2: HSA Elections |\n| --- |\n| If you are currently working (retirees do not complete this section):\u003Cbr>Annual employer contribution: $ \u003Cbr>Annual employee contribution* : $  Number of regular pay periods:   Contribution per pay period: $  (this is your employee contribution divided by number of pay periods)\u003Cbr>*The total employer and employee contributions cannot exceed IRS maximum limits.\u003Cbr>For 2027 , that limit is $9 ,000 for employees with family HDHP coverage, $4,500 for self-only coverage, and $1,000 additional catch-up contribution for employees aged 55 or older.\u003Cbr>For 2026 , the limits were $8,750 for family and $4,400 for self-only.\u003Cbr>Please note that your employer contributes $876 for an individual plan and $1,752 for a family plan , but only if you receive the employer share of the health premiums. |\n\n\n| Section 3: Applicant Authorization |  |\n| --- | --- |\n| You certify the information on this form is correct, and is applying to open an Health Savings Account with the Wisconsin Department of Employee Trust Funds Third-Party Administrator (TPA) . Once the HSA is opened, the TPA will serve as the custodian of your HSA, which consists of all the funds in your HSA deposit account, as well as any other investments you make with your HSA funds. You will receive a debit card linked to the HSA, subject to the Cardholder Agreement. You agree to return this form to your employer or benefits administrator and authorizes the TPA to share HSA details with the employer for account setup and maintenance. |  |\n| Subscriber Signature | Date (MM/DD/YYYY) |\n\nHSA Enrollment Terms and Conditions  \nI elect to participate in the Health Savings Accounts and agree to be bound by the terms of the Plan.  \nI understand that:  \n• The Health Savings Account (HSA) program is a benefit established for eligible state employees enrolled in one of the High Deductible Health Plans (HDHP) . The HSA program is authorized under Internal Revenue Service (IRS) Code Sections §125, §105, and §223 and Wisconsin Statutes §40 .515.  \n• A new enrollment must be ","cbCailJGvnEXg4D7","https://ap.wps.com/l/cbCailJGvnEXg4D7","pdf",290045,"English","# Section 1: Application Information\n# Section 2: HSA Elections\n# Section 3: Applicant Authorization\n# HSA Enrollment Terms and Conditions","[{\"question\":\"Who is eligible to open and contribute to an HSA on this form?\",\"answer\":\"Eligibility requires coverage by a qualified high-deductible health plan and meeting IRS requirements under Internal Revenue Code Section 223, including restrictions on other health plans and dependent status.\"},{\"question\":\"How are employee and employer HSA contributions determined?\",\"answer\":\"The form provides fields for annual employer contribution, annual employee contribution, number of regular pay periods, and the contribution per pay period. It also notes combined contributions cannot exceed IRS maximum limits.\"},{\"question\":\"What does the applicant authorize after signing?\",\"answer\":\"The subscriber certifies the information is correct and authorizes the third-party administrator to serve as custodian, provide a linked debit card under the Cardholder Agreement, and share HSA details with the employer for account setup and maintenance.\"}]","Health Savings Account (HSA) Enrollment - Terms and Conditions | PDF",1789809675]