Benepass HSA Beneficiary Designation

Health Savings Account (HSA) Beneficiary Designation
Please fill out the following information to designate a beneficiary for your Benepass Health Savings Account (HSA).

You will need the following information:

Your HSA Account Number

Your Personal Details

The personal details of your Beneficiary(ies)

Please complete this form in its entirety - it should take you less than 5 minutes!

Incomplete forms will not be saved.

Account Owner Details

Please confirm your personal details here. Only the account owner has the right to designate a beneficiary(ies).
Name

First NameLast Name
archived - Benepass HSA Account Number - don't use
12 digit number available in your HSA account details
Benepass HSA Account Number
12 digit number available in your HSA account details
Email
The email address you use to sign into your Benepass account
Secondary Email
A personal email if applicable
Phone Number
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date

Beneficiary Designation Guidelines
General: Please be sure to include all required information for each beneficiary. Providing this information can help expedite the claim process by making it easier to locate and verify beneficiaries.

Minors: While you may designate minors as beneficiaries, please note that claim payments may be delayed due to special issues raised by these designations. Proceeds may be paid to a duly appointed guardian of the child's estate. You may wish to consult with an attorney when drafting your beneficiary designation.

Life Status Changes: It is recommended that you review your beneficiary designation when various life status events occur, such as marriage, divorce, or birth of a child.

Tax Implications: Depending on the relationship to the account holder, certain beneficiary designations may be subject to exclusion from the traditional tax benefits of a Health Savings Account. You and your beneficiary may want to consult with a tax expert to understand these before submitting this form.

Beneficiary Designation
As the named Account Owner of the previously-referenced Health Savings Account (“HSA”), I have the right to designate the beneficiary or beneficiaries to whom any funds remaining in my HSA upon my death are to be paid and, at any time and from time to time prior to my death, to revoke, alter or amend any such designation previously made. Any such designation must be on a form provided by or acceptable to the Custodian and must be filed with the Custodian prior to my death. I hereby revoke completely every such designation previously made by me and I direct that, if I die before distribution of my HSA has been completed, the value of my Account shall be distributed to the Primary Beneficiary(ies) named below in the percentage(s) indicated, or in the absence of any percentages, in equal shares. The interest of any Primary Beneficiary who predeceases me shall terminate, and the percentage shares of all surviving Primary Beneficiaries shall increase ratably in proportion to the relative sizes of the percentages of such surviving Beneficiaries as originally set forth herein.
Beneficiary 1

Required
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Beneficiary 1 Percentage
Please designate a number out of 100

Beneficiary 2
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Beneficiary 2 Percentage
Please designate a number out of 100
b1 + b2 %
Total percentage allocated to beneficiaries must not exceed 100%
Beneficiary 3
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Beneficiary 3 Percentage
Please designate a number out of 100
b1 + b2 + b3 total %
Total percentage allocated to beneficiaries must not exceed 100%

Beneficiary 4
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Beneficiary 4 Percentage
Please designate a number out of 100
b1 + b2 + b3 + b4 total %
Total percentage allocated to beneficiaries must not exceed 100%
Additional Beneficiaries
If you are naming more than four (4) primary beneficiaries, please attach a separate signed and dated sheet, including the same required information as above for each entry.

Cancelof

Contingent Beneficiary Designation
I hereby designate the following person(s) as my Contingent Beneficiary(ies) to receive any funds remaining in my HSA upon my death, only in the event that all Primary Beneficiaries named above have predeceased me. The value of my account shall be distributed to the Contingent Beneficiary(ies) named below in the percentage(s) indicated, or in the absence of any percentages, in equal shares. The interest of any Contingent Beneficiary who predeceases me shall terminate, and the percentage shares of all surviving Contingent Beneficiaries shall increase ratably in proportion to the relative sizes of the percentages of such surviving beneficiaries as originally set forth herein.
Contingent Beneficiary 1

Optional
Name

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Date of Birth

MonthDayYear
Date
Beneficiary 1 Percentage
Please designate a number out of 100

Review
Please review your chosen beneficiary elections:
- {name88} {beneficiary182}%
- {name87} {percentage83}%
- {name95} {percentage93}%
- {name100} {percentage97}%

Other Provisions
A. Unnamed or Predeceased Beneficiaries

Required
If no Beneficiaries are named on this form or if all the named Beneficiaries predecease me, the HSA funds will be paid to my estate. If my spouse receives the HSA as a result of being named as Beneficiary, my spouse may choose to continue the HSA in his or her name, subject to Custodian’s consent, by providing a written election to the Custodian and by signing the forms and providing the information the Custodian requires. For any non-spouse Beneficiary, the HSA terminates as of my date of death and becomes payable. I understand that in certain states, my spouse’s consent may be necessary if I wish to name a person other than or in addition to my spouse as Beneficiary, and that I should consult with my attorney before making such a Beneficiary Designation.

By making the foregoing Beneficiary Designation, I represent and warrant to the Custodian that this Beneficiary Designation satisfies all legal requirements under applicable law and, on behalf of myself, the Beneficiary(ies), my heirs and my estate, I hereby indemnify and hold the Custodian harmless from and against any and all claims, damages, liabilities and costs (including attorney’s fees) arising as a result of the Custodian’s payment of my HSA in accordance with this Beneficiary Designation. Custodian may condition payment to any Beneficiary on satisfactory proof of identity and entitlement to payment.
I have read and acknowledge the above provision:
B. Spousal Consent

Optional
Note: The following section should be signed in the event your state requires the consent of your spouse to the designation of a beneficiary other than such spouse with respect to the HSA.

This could apply, for example, if you live in a community or marital property state and you designate someone other than or in addition to your spouse as a beneficiary. Consult your attorney or tax advisor for further information.

The undersigned spouse of the Account Owner in whose name the HSA identified above is opened hereby consents to and joins in the designation of the beneficiary(ies) identified previously. To the extent the undersigned spouse is not named as Beneficiary, such spouse relinquishes any interest such spouse may have in the funds contained in the HSA.
Spouse Name

First NameLast Name
Spouse Signature
Today's Date

MonthDayYear
Date
Should be Empty:

Health Savings Account (HSA) Beneficiary Designation

Account Owner Details

Beneficiary Designation Guidelines

Beneficiary Designation

Beneficiary 1

Beneficiary 2

Beneficiary 3

Beneficiary 4

Additional Beneficiaries

Contingent Beneficiary Designation

Contingent Beneficiary 1

Review

Other Provisions

A. Unnamed or Predeceased Beneficiaries

B. Spousal Consent