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Health Savings Account (HSA) Inquiry Form

* Indicates fields are required
Ex. mm/dd/yyyy
Ex. ###-###-####
Ex. ###-###-####
ex. joe@example.com
Ex. mm/dd/yyyy
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.
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
Ex. ###-###-####
Ex. ###-###-####
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