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Agent/Broker Sign-up Form

* Required

Thank you for considering HSA Bank for your clients' Health Savings Accounts (HSAs), Flexible Spending Accounts (FSAs), and Health Reimbursement Arrangements (HRAs).

After you complete this sign-up form, pending any discrepancies, we will assign you with an Agent Identification Number (AIN). The AIN allows us to track your referrals and offer you revenue sharing opportunities. Once your AIN has been assigned, you will receive a welcome e-mail (we will send it to the e-mail you provide), and you will gain access to our secure Partner Support Site. If you have any questions about our products or services, please contact a Business Relations Representative at (866) 357-5232, Monday through Friday (except holidays), 7 a.m. - 7 p.m., Central Time.

IMPORTANT NOTICE
This sign-up form is intended for INSURANCE AGENTS, FINANCIAL ADVISORS and INSURANCE AGENCIES only. If you are a different type of relationship (i.e. employer, healthcare provider, broker dealer, etc.) please contact our Business Relations Representative at (866) 357-5232 to register with HSA Bank and begin taking advantage of the services we offer.

General Information
* First Name: 
* Last Name: 
 P.O. Box?: 
* Street Address: 
* City: 
* State: 
* Zip Code: 
* Primary Phone Number:  - - ext.
Alternate Phone Number:  - - ext.
Fax Number:  - -
* Who would you like your commission paid to? 
* ID Type: 
* ID Number:   
* E-mail Address: