HSA Quick Start Employer Setup Form
Please complete all requested information and email or fax the completed form to the BenefitWallet
Employer Support Team. You can contact the Employer Support Team for answers to your specific
questions regarding the payroll process. Contact information is provided below.
SUBMIT THIS COMPLETED FORM TO:
BenefitWallet - Employer Support Team
Fax:
201-633-0134
Email:
[email protected]
Phone:
866-712-4551
Section 1. Employer Information
Employer Name:
(required)
Address – Line 1:
(required)
Address – Line 2:
City : (required)
State: (required)
Zip: (required)
Contact Information
HSA Payroll Contact Name:
HSA Payroll Contact Phone:
HSA Payroll Contact Email:
Additional Contact Name:
Additional Contact Phone:
Additional Contact Email:
Broker Contact Information
Broker Name:
Broker Phone:
Broker Email:
Section 2.
Health Plan Information
Health Plan Effective Date: (required):
Number of benefit eligible employees:
Expected number of HSA accounts:
*If you are unsure of the expected number of employees that will elect the
HSA, please indicate this by entering “NA”
HSA Quick Start Checklist
The following checklist will help guide you through the automated steps of the Quick Start program. For
additional details you may contact the Employer Support team at 1-866-712-4551 or email
[email protected].
Step 1.
Employer
Setup
Complete the Quick Start Employer Setup form and submit the form to the Employer Support team by email
([email protected]) or fax (1-201-633-0134).
Within two business days after we receive the Quick Start Employer Setup Form, we will complete the employer activation
and send three emails to the payroll contact listed on the form. The three emails include:
Step 2.
Employer
Activation
And
Notification
Email 1-Welcome email: The welcome email confirming the group set-up is complete as well as instructions on how to:

access the employer web site

use Payroll on the Web (POW!) for contributing to your employees’ HSAs

use online web reporting

find additional training and user guides.
Email 2-Employer authentication email: This email provides information on how the employer can designate additional
authorized contacts for our team to assist with day-to-day questions.
Email 3-HSA Funding instructions and temporary password email: This email provides HSA funding instructions and
your temporary Web password.
You will use the Group Online Enrollment tool to upload enrollment information for employees who are eligible for an HSA.
After you log on to the web site, click the Group Online Enrollment tab to access the enrollment spreadsheet. Populate the
spreadsheet, click the icon to save the enrollment information as a text file, then upload the file. Employees will be
required to activate their HSAs after you complete this step (described in Step 4).
Step 3.
Employer
Login and
Employee
Enrollment
An alternate approach to submitting enrollment information is to submit one-by-one enrollments by selecting “Enroll an
Individual Employee”. This is best suited for employers with very few enrollments or for adding new members throughout
the year.
We will set up an HSA for each employee that was sent through Group Online Enrollment tool. Enrollment information
initiates a mailing with additional details to your employees the following day.
Enrollments successfully loaded will display on Web Reporting and Payroll on the Web within one business day.
You may review the Group Online Enrollment Guide located on the Group Online Enrollment tab on the employer web
portal.
Step 4.
Typically, members can begin activating their HSAs the day after they have been entered through the Group Online
Enrollment tool. It is very important that you communicate the importance of account activation since the employer cannot
fund an account until after it is open.
Employee
Account
Activation
We recommend activation through the electronic signature process. Direct your employees to www.mybenefitwallet.com
and click on First Time User. Completion of the e-signature process includes agreeing to the terms and conditions of the
account and activating their account.
Funds are submitted by an employer in a lump sum by ACH, wire or check in addition to instructions telling us how to
distribute those funds to each account.
Step 5.
Funding
“Payroll on the Web” (POW) is the primary funding tool used to deposit pre-tax employee or employer contributions to your
employee’s HSAs. This innovative service enables employers to provide HSA contributions online at any time.
For more detailed information on Payroll on the Web, please visit the full demonstration available at
http://www.brainshark.com/acs-inc/Payroll_on_the_web.