• The Delta HSA Advantage
• Description of Services
• Find an HSA Eligible Plan
• Services & Fees
• Documents and Forms

Documents and Forms

For the convenience of our clients—brokers and consultants, employers and individual subscribers—a number of key documents and forms can be downloaded and printed from this site.

The following files require Adobe Acrobat Reader — free software for viewing and printing PDF files.

General Information

•  Frequently Asked Questions (PDF, 49K)
•  Standard Plan Fee Schedule (PDF, 21K)
•  Value Plan Fee Schedule (PDF, 21K)
•  eSavings Fee Schedule (PDF, 17K)
•  Steps to Set Up Account (PDF, 18K)

For Brokers & Agents

•  How to Set-Up an HSA (PDF, 18K)
•  Broker Checklist (PDF, 50K)

For Employers

•  Employer Group Application (PDF, 71K)
•  Employer Application Kit (PDF, 21K)
•  Delta Service Packages & Fees (PDF, 29K)

For New Subscribers to Enroll

•  Individual Enrollment Application (PDF, 89K)
•  Individual Enrollment Kit (PDF, 597K)

For Current Account Holders

•  Request for Debit Card Form (PDF, 19K)
•  Deposit Form (PDF, 15K)
•  Request for Funds Disbursement Form (PDF, 26K)
•  Account Change Form (PDF, 71K)
•  Account Termination Form (PDF, 25K)
•  Roll-Over Request Form (PDF, 16K)

Account Agreements

•  Administrative Agreement (PDF, 32K)
•  Custodial Agreement (PDF, 38K)