Investment Options

For more information or to enroll online:

(888) 354-0697 Monday- Friday, 8:30 am-5 pm ET

Simply put, an HSA is a tax-favored health savings account for people with a qualified high-deductible health plan. An HSA provides triple tax savings.

Contributions are tax deductible. Growth in interest and earnings are tax free. Withdrawals for eligible medical expenses are

tax free.

HSA Eligibility

Federal regulations require you to meet all of the following eligibility requirements in order to open and contribute to an HSA:

Covered under a qualified high deductible health plan on the first day of the month.

Not covered by any other health plan, including your spouse's health insurance.

Not covered by your own or spouse's Medical Flexible Spending Account (FSA).

Not enrolled in any part of Medicare or Tricare. Have not received Veteran's health benefits in

the past 90 days. Not claimed as a dependent on another

person's tax return.

Annual Contribution Limits

Single Account Family Account Catch up (age 55 and older)

2017 $3,400 $6,750 $1,000

2016 $3,350 $6,750 $1,000

Catch up provision if you are age 55 or older by December 31 of the tax year

Maximum includes employer contribution

Investment Options

Our members have the option to access the money via a debit card or invest in a portfolio of funds whereby the money can potentially grow tax free, or both.

Vanguard No-load Mutual Funds Choose up to four of the 22 Vanguard? mutual funds offered No minimum contribution required Low expense ratios No transaction or redemption fees Not FDIC insured

Debit Card APY varies based on account balance FDIC insured No monthly low-balance fee

NOTE: Debit Card cannot access Vanguard Funds

Accessing and Saving HSA Funds

An HSA is much like a savings account, but the funds are reserved just for eligible healthcare expenses. Once an eligible medical or prescription expense is incurred, you have the following two options:

1) Pay from your HSA... Use with your debit card (if elected), or Request a withdrawal from your Vanguard funds

OR

2) Pay out of pocket and let your HSA grow. There is no time limit on reimbursements

Tip: Remember to keep your receipts so you can reimburse yourself in the present or future for eligible medical expenses. View the IRS Publication 502 for a list of all eligible medical expenses.

Three simples steps to get started

1. Confirm your health insurance plan is HSA qualified.

2. Select your investment options ? Vanguard Funds, debit card, or a combination of both.

3. Complete the HSA enrollment form or enroll online at .

Health Savings Account (HSA) Enrollment & Agreement

PLEASE NOTE that you can complete the entire enrollment process online at . If setting up the account through your employer, please ask your benefits or human resources department for specific enrollment instructions.

STEP 1 Review HSA Eligibility Requirements

STEP 2

Tell Us Who You Are Provide your personal information.

STEP 3

Authorized Signer (optional) Designate an authorized signer (such as a spouse or another third party) to access and initiate transactions on your account.

STEP 4

Beneficiary Designation Complete this section to designate beneficiaries to receive payment of the value of your HSA following your death.

STEP 5

Investment Allocation Elect your investment allocations.

STEP 6

Signature Please be sure to sign your application in ink. We cannot process your application without your signature.

Addendum Custodial Account Agreement

Rev. 08/2015

10800 Midlothian Turnpike, Suite 240 Richmond, VA 23235 (p) 888.354.0697 (f) 804.726.1570

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Health Savings Account (HSA) Enrollment & Agreement

STEP 1 Review HSA Eligibility Requirements

Federal regulations require you meet all of the following eligibility requirements to open and contribute to an HSA: > Covered under a qualified high deductible health plan on the first day of the month* > Not covered by any other health plan, including your spouse's health insurance > Not covered by your own or spouse's medical Flexible Spending Account (FSA) (unless it qualifies as a "limited purpose" FSA)* > Not enrolled in any part of Medicare or Tricare > Have not received Veteran's health benefits in the past 90 days > Not claimed as a dependent on another person's tax return

You are not subject to these eligibility requirements to open an HSA with us if you are only transferring funds from an existing HSA.

*Contact your health insurance provider to confirm that your plan is HSA compatible and any FSA for which you are eligible qualifies as "limited purpose." Health Savings is not able to determine if your health plan is qualified or if your FSA is "limited purpose."

STEP 2 Tell Us Who You Are

Salutation q Mr. q Ms. q Dr.

First Name_________________________________________ Last Name___________________________________________ M.I._________

Social Security Number ________ ? ______ ? ______________

Date of Birth (mm|dd|yyyy) ______ / ______ / ____________

Primary Address (P.O. Boxes not accepted)_____________________________________________________________________________________________________

Address 2 (P.O. Boxes not accepted)____________________________________________________________________________________________________________

City_________________________________________________________ State__________ ZIP___________________ Country___________________________

Mailing Address (If different from primary address)_______________________________________________________________________________________________

Address Line 2_____________________________________________________________________________________________________________________________

City_________________________________________________________ State__________ ZIP___________________ Country___________________________

Primary Phone Number ___________________________________ Secondary Phone Number______________________________________

Primary Email Address* ___________________________________ Secondary Email Address______________________________________

Receive email notifications?* q Yes q No

If not a U.S. Citizen, enter country of citizenship__________________________________________________________________________________________

Employment Status: q Employed q Self Employed q Not Employed/Retired

Employer Name___________________________________________________________________________________________________________________________

Health Plan Type: q Single q Family

Effective Date of Qualified Health Insurance (mm|dd|yyyy) ______ / ______ / ____________ Health Insurance Carrier________________________________________________________________________________________________

*By providing an email address and checking the "Yes" box, the account holder represents and warrants that he/she consents and has the ability to receive the electronic delivery of all investment-related, account-related information and notices at the provided email address. Electronic delivery may include, but is not limited to, emailed copies of or internet links to documents in PDF format. Investment-related and account-related information and notices may include, but is not limited to fund prospectuses, tax notices, account statements, confirmations of statements, account access passwords, etc. Account holder's consent will be in effect until revoked. Account holder may request no-cost written copies of any electronically delivered documents and/or may revoke his/her consent to electronic delivery by contacting Customer Service.

Rev. 08/2015

10800 Midlothian Turnpike, Suite 240 Richmond, VA 23235 (p) 888.354.0697 (f) 804.726.1570

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Health Savings Account (HSA) Enrollment & Agreement

STEP 3 Authorized Signer (optional)Requirements

By completing all of the fields below, you are authorizing the person designated as authorized signer (such as a spouse or another third party) to access and initiate transactions on your account. Federal law requires all financial institutions to obtain, verify and record information that identifies each person associated with an account. When you add an authorized signer to your account, you must provide their name, Social Security number and date of birth to help us identify him/her. NOTE: Authorized signers must be age 18 or older.

Salutation q Mr. q Ms. q Dr.

First Name_________________________________________ Last Name___________________________________________ M.I._________

Social Security Number ________ ? ______ ? ______________

Date of Birth (mm|dd|yyyy) ______ / ______ / ____________

STEP 4 Beneficiary Designationts

The following individual(s) or entity(ies) shall be my primary and/or contingent beneficiary(ies). If neither primary nor contingent is indicated, the individual or entity will be deemed to be a primary beneficiary. If more than one primary beneficiary is designated and no distribution percentages are indicated, the beneficiaries will be deemed to own equal share percentages in the account. Multiple contingent beneficiaries with no share percentage indicated will also be deemed to share equally. If a primary or contingent beneficiary dies before me, his or her interest and the interest of his or her heirs shall terminate completely, and the percentage share of any remaining beneficiary(ies) shall be increased on a pro-rated basis. If no primary beneficiary(ies) survives me, the contingent beneficiary(ies) shall acquire the designated share of my account.

Name

(or Trust and Trustee)

Date of Birth

Social Security # Relationship Primary or

(mm/dd/yyyy)

(TIN, if Trust)

(creation date, if Trust)

Contingent

Share %

q Spouse

q Primary q Contingent

%

q Primary q Contingent

%

q Primary q Contingent

%

q Primary q Contingent

%

q Primary q Contingent

%

Rev. 08/2015

10800 Midlothian Turnpike, Suite 240 Richmond, VA 23235 (p) 888.354.0697 (f) 804.726.1570

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Health Savings Account (HSA) Enrollment & Agreement

STEP 5 Investment Allocation

Use this form to elect your investment allocations for your health savings account. You can learn more about these individual investment options at . Once your account becomes active, you can make or change your investment elections online.

Fund

*Cash (Debit Card optional) Vanguard? Prime Money Market Fund Investor Shares Vanguard? GNMA Fund Admiral Shares Vanguard? LifeStrategy Income Fund Vanguard? Total Bond Market Index Fund Admiral Shares Vanguard? LifeStrategy Conservative Growth Fund Vanguard? Balanced Index Fund Admiral Shares Vanguard? LifeStrategy Moderate Growth Fund Vanguard? STAR Fund Vanguard? WindsorTM II Fund Admiral Shares Vanguard? LifeStrategy Growth Fund Vanguard? 500 Index Fund Admiral Share Vanguard? Total Stock Market Index Fund Admiral Shares Vanguard? Social Index Fund Investor Shares Vanguard? Selected Value Fund Investor Shares Vanguard? MorganTM Growth Fund Admiral Shares Vanguard? International Growth Fund Admiral Shares Vanguard? Mid-Cap Index Fund Admiral Shares Vanguard? Total International Stock Index Fund Admiral Shares Vanguard? Extended Market Index Fund Admiral Shares Vanguard? Strategic Equity Fund Vanguard? Small-Cap Index Fund Admiral Shares Vanguard? Mid-Cap Growth Fund Investor Shares Percentages must add up to 100%, only whole percentages are allowed

Ticker

- - VMMXX

VFIJX VASIX VBTLX VSCGX VBIAX VSMGX VGSTX VWNAX VASGX VFIAX VTSAX VFTSX VASVX VMRAX VWILX VIMAX VTIAX VEXAX VSEQX VSMAX VMGRX

TOTAL

Elections

% % % % % % % % % % % % % % % % % % % % % % %

100 %

Account Options:

Debit Card(s):

q I would like to order a debit card for myself. q I would like to order a debit card for my authorized signer.

*If you request a debit card, you must allocate a portion of your contribution into the Cash option listed above.

Statement Preferences:

q I would like to receive e-statements. q I would like to receive paper statements. I will also receive paper bank disclosures, notices and tax documents.

SUMMARY OF FEES: (Please see the Custodial Account Agreement for a full listing of fees.)

Administrative Fee: $45 per year. This fee will be deducted from my account annually. (Note: If enrolling with an employer group, this fee may be paid in full, or in part, by your employer.)

Mutual Fund Specific Fee: 6.25** basis points per quarter (i.e, $0.625 cents per $1,000 every three months). Fees will be deducted from the account balance quarterly.

**Vanguard funds only

Rev. 08/2015

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10800 Midlothian Turnpike, Suite 240 Richmond, VA 23235 (p) 888.354.0697 (f) 804.726.1570



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