Premier Health Savings (HSA)

Please fill out the fields in the form below. One of our representatives will contact you within one business day to complete the process.

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    IMPORTANT INFORMATION ABOUT PROCEDURES FOR OPENING A NEW ACCOUNT - To help the government fight the funding of terrorism and money laundering activities, federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account. What this means for you: When you open an account, we will ask for your name, address, date of birth, and other information that will allow us to identify you. We may also ask to see your driver's license or other identifying documents

Personal Information

  • Are you a new customer?

    OKAre you a new customer? is required
  • Enter full legal name, including middle initial as appropriateOKName is required
  • Social Security Number

    --
    OKSocial Security Number is required
  • Drivers License or other government issued IDOKIdentification Number is required
  • OKState Issued is required
  • Issue Date

    OKIssue Date is required
  • Expiration Date

    OKExpiration Date is required
  • Date of Birth

    OKDate of Birth is required
  • Home Phone

    --
    OKHome Phone is required
  • Daytime Phone

    --
    OptionalOKDaytime Phone is required
  • OKMother's Maiden Name is required
  • OKEmail is required

Insurance Information

  • OKWho is your insurance carrier? is required
  • OKWhat is your insurance plan deductible? is required
  • OKWhat is your insurance plan effective date? is required
  • OKWhat is your insurance coverage type? With options of “Individual” or “Family” is required

Address Information

  • OKPhysical Address (Not a P.O. Box) is required
  • OKCity is required
  • OKState is required
  • OKZip is required
  • Use physical address for mailing address

    OKUse physical address for mailing address is required
  • OKMailing Address (if different than above) is required
  • OKCity is required
  • OKState is required
  • OKZip is required

Authorized Signer Information

  • Number of Authorized Signers

    OKNumber of Authorized Signers is required

Authorized Signer #1

  • OKRelationship to Primary Applicant is required
  • Enter full legal name, including middle initial as appropriateOKName is required
  • Social Security Number

    --
    OKSocial Security Number is required
  • Drivers License or other government issued IDOKIdentification Number is required
  • OKState Issued is required
  • Issue Date

    OKIssue Date is required
  • Expiration Date

    OKExpiration Date is required
  • Date of Birth

    OKDate of Birth is required
  • Home Phone

    --
    OKHome Phone is required
  • Work Phone

    --
    OKWork Phone is required
  • OKPhysical Address is required
  • OKCity is required
  • OKState is required
  • OKZip is required

Beneficiary

  • OKRelationship to Primary Applicant is required
  • Enter full legal name, including middle initial as appropriateOKName is required
  • Social Security Number

    --
    OKSocial Security Number is required
  • Date of Birth

    OKDate of Birth is required
  • OKPhysical Address is required
  • OKCity is required
  • OKState is required
  • OKZip is required

Comments

  • OptionalOK is required

Security Code

  • OK is required
  • Idaho Independent Bank reserves the right to use the above information to obtain verifications of identity and background before opening any accounts. We may also access information about you from a consumer reporting agency, such as a copy of your credit report, before opening any account. By submitting this form, you grant full permission to do so.