Health Savings Account Application

If your employer offers a High Deductible Health Plan, there is important information you should know before applying for your account. Read our Frequently Asked Questions for more details.

First, Set-Up Your Account

  1. Download and print a copy of the disclosures listed below for your records:

  2. After clicking the I'd like to apply for a Health Savings Account link below, please print and complete the application. You will need to sign your completed application in front of a Notary if you are not an existing 1st Source checking account client.
  3. If you will have an authorized signer on your account, please complete the Authorized Signer section on the application.
  4. Include a check for your initial deposit payable to 1st Source Bank (or you may wait for employer funding).
  5. Mail the forms and your deposit to:

    1st Source Bank
    Online Banking Department
    205 W. Jefferson Blvd., Suite 100
    South Bend, IN 46601

  6. After we receive your notarized documents and opening deposit, your HSA account will be opened and account materials will be mailed to you.

Next, Start Your Application
To start your application, please click the button below to indicate you are at least 16 years old, and you have read and agree with the disclosures and agreements listed above.