Sterling Health Savings Account (HSA)
	Administrative Services Agreement This Administrative Services Agreement is made between Sterling Health Services, Inc. and the individual who signs the Sterling HSA Enrollment Form., 6 Pages (Rev. 12/2011)
	Application Employer Group 2 Pages (Rev. 4/2011)
	Beneficiary Designation Form Beneficiary designation to be made by all applicants, 2 Pages (Rev. 11-2011)
	Change Request Form To change account information, 1 Page (Rev. 11/2011)
	Custodial Agreement This Custodial Agreement is made between CitizensTrust, and individual who signs the Sterling HSA Enrollment Form, 5 Pages (Rev. 4/2011)
	Deposit Form Deposit Form – Individual HSA Contribution, 1 Page (Rev. 12/2011)
	Employee Enrollment Kit How to Set-up a HSA Account, 13 Pages (Rev. 12/2011)
	Employee Payroll Deduction Salary Redirection Agreement for Health Savings Account, 1 Page (Rev. 7/2011)
	Employer ACH Authorization Form Credit / Debit Authorization Form, 1 Page (Rev. 7-10)
	Employer Enrollment Kit An employer's "How To" kit, 5 Pages (Rev. 12/2011)
	Guide to Tax Related HSA Questions Sterling does not give tax advice, consider these as informed guidelines. Specific tax questions should be referred to your CPA or tax preparer., 1 Page (Rev. 12/2011)
	Health Savings Account Administration Instructions 6 Pages (Rev. 2/2011)
	Request for Debit Card To request debit card, 1 Page (Rev. 9-2010)
	Request for Disbursement To request disbursements, 1 Page (Rev. 3/2011)
	Sterling Service Packages & Fees 1 Page (Rev. 8/2011)
	Terminate Account Form To close your account with Sterling HSA, 1 Page (Rev. 8/2011)

Sample Eligible Expenses for HSAs, HRAs and FSAs
	Sample Eligible Expenses Sample expenses list - intended as a quick reference guide only. For a list of qualified HSA expenses please see IRS Publication 502 Section 213 (d). (Rev. 6-2011)

Sterling Flexible Spending Benefits Account
	FSA Application Employer 6 Pages (Rev. 3/2011)
	FSA ApplicationEmployee 1 Page (Rev. 3/2011)
	FSA Change Form 1 Page (Rev. 11/2011)
	FSA Disbursement Form 1 Page (Rev. 3/2011)
	FSA Termination Form 1 Page (Rev. 12/2011)

Sterling COBRA -Consolidated Omnibus Budget Reconciliation Act
	COBRA Beneficiary Takeover Form 2 Pages (Rev. 8/2011)
	COBRA Employer Application 5 Pages (Rev. 11/2011)
	COBRA Qualifying Event Form 2 Pages (Rev. 11/2011)

Sterling Health Reimbursement Arrangements (HRA)
	Application - Employer Employer Information, 9 Pages (Rev. 4/2011)
	Application - Individual Employee Information, 1 Page (Rev. 4/2011)
	Employer ACH Authorization Form Credit / Debit Authorization Form, 1 Page (Rev. 7-10)
	HRA Informational Brochure 2 Pages (Rev. 7-2010)
	HRA Participant 1 Page (Rev. 7-2010)
	Medical Claim Form 1 Page (Rev. 3/2011)
	Request for Dependent Debit Card Use this form to request a new debit card or additional debit card(s) for your dependents on your HRA account., 1 Page (Rev. 12/2011)
	Services Fees Funding Options 2 Pages (Rev. 9-2010)
	Termination/Change Form Health Reimbursement Arrangement Account Change or Termination Form, 1 Page (Rev. 1/2012)

Sterling Section 125 Premium Only Plans (POP)
	POP Application 6 Pages (Rev. 11/2011)
	POP Brochure Section 125 Premium Only Plans, often referred to as POP Plans, reduce income tax liabilities for employers and employees., 2 Pages (Rev. 8/2010)
	POP Election Form Election Form to Participate in Section 125 Premium Only Plan, 1 Page (Rev. 11/2011)
	POP Participant (Rev. 10/2010)

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