This form is to be completed by the employer on behalf of the employee(s) enrolled in the Alliance Health Plan group coverage.

Employer Information

Employer Name *

Employer Location or Church Code

Employer Tax ID Number (EIN) * 🛈

For the Month(s) of:

Employee
Name

Employer Monthly HSA
(included in Silver Plan premium)

Employer Additional
Monthly HSA

Employee Additional
Monthly HSA

Total Monthly HSA
Amount

Employee
Name

Employer Monthly HSA
(included in Silver Plan premium)

Employer Additional
Monthly HSA

Employee Additional
Monthly HSA

Total Monthly HSA
Amount

Employee
Name

Employer Monthly HSA
(included in Silver Plan premium)

Employer Additional
Monthly HSA

Employee Additional
Monthly HSA

Total Monthly HSA
Amount

Employee
Name

Employer Monthly HSA
(included in Silver Plan premium)

Employer Additional
Monthly HSA

Employee Additional
Monthly HSA

Total Monthly HSA
Amount

*No monthly Employer HSA Contribution is required for participants enrolled in the Bronze Plan. Additional contributions are optional.

Additional Employer HSA Notes:

HSA Eligibility and Limitations

The 2024 annual maximum contribution amounts per IRS regulations are $4,150 for individual coverage and $8,300 for a family. An additional $1,000 annual contribution is allowed for those age 55 and older. These maximums include both employer and employee contributions combined.

According to the IRS, employees that fall under any of the following categories below are not eligible to contribute to a Health Savings Account (HSA):
• are enrolled in Medicare, Tricare or a Veteran’s plan
• are enrolled in additional coverage on a PPO Health Plan
• are claimed as a dependent on another person’s taxes

A dependent is eligible to enroll in an employee’s HDHP plan but HSA funds cannot be used for said dependent if employee does not claim them on their taxes.

I have read the HSA Eligibility and Limitations section of this form and agree that it is the participant’s responsibility to be in compliance with IRS rules regarding an HSA. Alliance Benefits is not responsible for an ineligible employee participating in an HSA. Alliance Benefits must be notified if an employee is ineligible for an HSA. Be aware that tax penalties may apply if the annual maximum contribution amounts are exceeded.

Employer Authorization and Signature

I hereby authorize ALLIANCE BENEFITS to withdraw funds for the above HSA contributions listed.

I understand this is tied to the health plan insurance premium and will be billed at the same time. For retro effective dates, the HSA contribution will be deducted and begin on the following month after receipt of this form. The funds will then be deposited to the employee’s HSA account by the 10th of the following month. Changes must be submitted to Alliance Benefits by the 25th of the month to be included in the following month’s billing.

Alliance Benefits must be notified of terminations of employment or ending of coverage immediately by completing the End of Coverage form located on the website www.alliancebenefits.org. HSA contributions cannot be refunded once collected.

All HSA contributions must be reported on Employee’s W-2, Box 12, Code W.

The undersigned employer representative confirms that this applicant is a paid employee of the above named organization, working 20 or more hours per week, and that the reported salary is accurate. We understand the Health Plan coverage being requested by this applicant, upon approval, will be added to our employer’s monthly billing statement. (The employer representative cannot be the applicant.)

Authorized Employer's Printed Name *

Authorized Employer's Title *

Contact Phone Number *

Email Address *

Authorized Employer's Signature *

clear

Signature Date * +