Health Savings Account Enrollment Form 2024-2025

Plan year July 1, 2024 through June 30, 2025

Use this form if you are enrolling in the UK Saver HSA health plan and would like to make additional employee contributions. This also includes the option to open a limited flexible spending account. You must download the form and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.