Click Here to Download our 2010 HSA Application!

Please note our application contains fillable fields. Once you open the application in ADOBE Reader, you can complete most of the application on the computer. However, at any point you can print the application and complete the remaining information by hand. After you complete the application, you can mail, fax or scan/email it to Great Lakes HSA. We will send you a confirmation email as soon as your application is received.

Although you do not need a deposit to open your account, please remember to mail us $25 for the annual fee. Once the account is opened you can make your first deposit.

Although your account is opened the same day its received, it will take 5 days for you to receive the formal welcome packet, and 7 days to receive free debit card.
You can download our PDF welcome packet here

Send us your Application

Fax it to 480-275-3096 (and mail us your annual fee)

Mail to:

Great Lakes HSA,
1100 Superior Ave, Suite 1700
Cleveland, OH 44114

Email: info@greatlakeshsa.com