Employee HSA Account Adjustments and Authorization

Business Name:

Business Phone Number:

Employee Name:

Employee HSA Account Number:

Employer Code:

Employee Information Update

Employee Name Change:

Employee Address Change:

HSA Contribution Adjustments

The owners of the accounts authorize and direct Nicolet National Bank to:

Effective Date:

*Please note terminations can take up to 15 business days to be updated.

If changed, amount to be transferred:

Business Account Information

Name of Person Authorizing:

Business Account Number:

The business account and employee accounts remain subject to their individual terms and conditions, which are not modified by this authorization. If no termination date is specified above, this authorization will remain in effect until terminated by any one of us. You may terminate this authorization by giving us 15 days notice.

Name: (digital signature)

If you have any questions please contact Pete Gobis (920) 406-2489 [email protected] or Chas Hartl (920)617-8208 [email protected]