Sterling HSA Forms
	Account Change Form To change account information, 1 Page (Rev. 10/04)
	Beneficiary Designation Form Beneficiary designation to be made by all applicants, 2 Pages (Rev. 10/04)
	Custodial Agreement Applicant signature on the Individual Application acknowledges receipt and acceptance of these terms, 3 Pages
	Deposit Form For submission of individual deposits, 1 Page (Rev. 10/04)
	Group Application Kit Includes Employer How To Checklist, Employer Group Application, Census Form, 5 Pages
	Individual Application Includes Accountholder Application, Catch-Up Contribution Application, Beneficiary Designation Form., 5 Pages (Rev. 9/06)
	List Bill Use to list contribution data for subsequent transactions, 1 Page
	Referral Agreement Broker agreement., 2 Pages
	Request for Debit Card To request debit card, 1 Page (Rev. 10/04)
	Request for Disbursement of Sterling HSA Funds To request disbursements, 1 Page (Rev. 10/04)
	Termination of Sterling HSA Account To terminate an individual's account, 1 Page (Rev. 10/04)

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For additional information, please contact Claremont at 800.696.4543 or info@claremontcompanies.com