Health Savings Account(HSA) Inquiry Form

* Indicates fields are required

Ex: mm/dd/yyyy
Ex: joe@example.com
Do you currently bank with Simmons Bank?



Ex: mm/dd/yyyy
Do you want to order checks?



Do you need a debit card?
If a debit card is needed, a system generated PIN will be issued. However, once the card has been received a designated PIN can be chosen by visiting any Simmons Bank ATM.



Do you want to enroll in internet banking?





Do you want to designate an authorized signer on this account?
Authorized signers do not have ownership rights, nor can they receive account information – they can write checks and have a debit card if approved by the account owner.



**If an authorized signer is designated, complete the below section.**

Authorized Signer's Information

(No account ownership rights)
Ex: mm/dd/yyyy
Does the authorized signer need a debit card?
If a debit card is needed, a system generated PIN will be issued. However, once the card has been received a designated PIN can be chosen by visiting any Simmons Bank ATM.



Primary Beneficiary

Ex: mm/dd/yyyy
If more than one primary beneficiary, complete the fields below for additional primary beneficiary.

Additional Primary Beneficiary

Ex: mm/dd/yyyy

Contingent Beneficiary

Ex: mm/dd/yyyy
If more than one contingent beneficiary, complete the fields below for additional contingent beneficiary.

Additional Contingent Beneficiary

Ex: mm/dd/yyyy