Health Savings Account (HSA) Request Form

Note: As the employee you are responsible to setup your own HSA bank account prior to submitting this request to HR/Accounting. Reach out with questions. hr@scswiderski.com

This benefit can be used with Anthem - Option 1B and Option 1C only.

HSA Request Form

HSA Request Form

Health Savings Accounts (HSA) 2025 Form - Click Here!

Please print this document from self-service portal on Paylocity under Benefits, or reach out to Human Resources. Thank you