Plan year July 1, 2021 through June 30, 2022
Use this form if you are enrolling in the UK Saver HSA health plan and would like to make additional employee contributions. This also includes the option to open a limited flexible spending account. You must download the form and save it to your computer to complete the digital signature. Viewing the form in a web browser will not allow a digital signature.
Revision date: 04/23/2021
Submit paper form to Benefits Office, 112 Scovell Hall, Lexington KY 40506-0064