Health Savings Account (HSA)

<Is it possible to only have this show up so long as they either are currently enrolled in and are keeping the same OR elected to change to one of the following health insurance options?>

High Deductible

Single

High Deductible

Employee + 1

High Deductible

Family

Current contribution per paycheck: <HSA>

I elect a biweekly contribution of $________ beginning with the January 3, 2014 paycheck.

Note: You may elect $0 and Cornell College will still contribute $12.50 per paycheck.

<If they are enrolled in the "High Deductible

Single"  and the DOB field is greater than 1/1/1958, the max they can elect is $115.38>

<If they are enrolled in the "High Deductible

Employee + 1 OR High Deductible Family" and the DOB field is greater than 1/1/1958, the max they can elect is $240.38>

< If they are enrolled in the "High Deductible

Single" and DOB field is less than 1/1/1958, the max they can elect is $153.84>

< If they are enrolled in the "High Deductible

Employee + 1 OR High Deductible Family" and DOB field is less than 1/1/1958, the max they can elect is $278.84>

   I authorize Cornell College to deduct, on a pre-tax basis, the elected amount from my biweekly pay. I hereby consent that all personal information and selections made are correct.

Disclaimer: HSAs are personal health savings vehicles rather than group employee benefits, Although Cornell College has agreed to forward contributions through its payroll system to U.S. Bank, it has not specifically endorsed U.S. Bank or any other HSA provider. You are not restricted from moving funds to another HSA, but your employer is not required to forward payroll contributions to another HSA provider. With respect to HSAs offered through U.S. Bank, employers may not impose conditions on the use of HSA funds, make or influence any investment decisions with respect to funds contributed to an HSA, or receive any payment or compensation in connection with an HSA.