ACCOUNT LOGIN
User ID
User ID / Password Help

Getting Online Guide

Card Services


divder_line divder_line divder_line divder_line divder_line divder_line
sidebar_background_extend

Forms

These forms are being provided for your convenience. The forms are in printable formats and may be mailed to us at:

Beniversal HSA
409 Silverside Road, Suite 105
Wilmington, DE 19809

If you have any questions, please call us at 800.473.9595 or email us at beniversalhsa@thebancorp.com.

Account Number Request Form
Please fill out and return to the Bancorp in order to receive your employee's account numbers. This form is used to facilitate the funding process for employers. If possible, please type all information into the fields before printing.

ACH Transfer
In lieu of a paper ACH request, you may utilize our online Funds Transfer functionality to make a one-time or recurring electronic money transfer between your account with us and your account at another financial institution.

Affidavit of Forged or Altered Check
This form will allow a customer to dispute that a check drawn from his/her account was either Forged or Altered. Please complete the form, sign before a Notary Public, and submit to The Bancorp Bank via mail for further processing. 

Affidavit of Unauthorized ACH
This form will allow a customer to dispute an Automated Clearing House transaction on their account. Please complete the form, sign and submit to The Bancorp Bank for further processing through mail or fax.

Change of Contact Information
This form can be used to update your name, e-mail address, telephone number, and home address information.

Direct Deposit/Payroll Deduction Form For HSA Account Holders
This form allows an employer, or other organization to establish direct deposit into a checking and/or savings account that you have selected. Please print this form and provide to your employer or other organization. They will complete the form and set up your funds to auto transfer into your account.

Health Savings Account (HSA) Contribution / Refund Deposit Slip
This form is used when depositing a refund check to your HSA or mailing in an HSA contribution.

Health Savings Account (HSA) Transfer/Rollover Form
Use this form to instruct The Bancorp Bank to transfer or rollover your Health Savings Account at another institution to a new account at The Bancorp Bank .

Health Savings Account (HSA) Employer Contribution Form
With this form an employer can make an initial deposit on behalf of multiple Health Savings Accounts for its employees.

Health Saving Account(HSA) Individual Contribution Correct Form
Please complete this form to report and correct an excess contribution to your Health Savings Account made during the current tax year.

IRA to HSA Transfer Form
Use this form to instruct The Bancorp Bank to transfer or rollover your IRA at another institution to an HSA account at The Bancorp Bank.

Medical Savings Account (MSA) Transfer/Rollover Form
Use this form to instruct The Bancorp Bank to transfer or rollover your Medical Savings Account at another institution to a new account at The Bancorp Bank.

Power of Attorney
This form allows a customer to designate another person to manage their account(s) at The Bancorp Bank. This person will have complete control of the account(s), however the power of attorney ceases to be recognized by The Bancorp Bank upon death of the accountholder. Please print, sign, notarize and submit this form to The Bancorp Bank for further processing by mail.

Remove Account Signer Request
Use this form to remove an authorized signer from your account.

Stop Payment
This form allows for a customer to stop the payment of a check or ACH on an account. Please call the toll-free number listed in the customer service tab to place the stop payment. A stop payment is only valid for 14 days without this signed and submitted form. Once the form is received by The Bancorp Bank the stop payment will be valid for 6 months.

Wire Request Form for Deposit Accounts (Domestic)
Complete this form to transfer funds by wire to another U.S. bank.

Wire Request Form for Deposit Accounts (International)
Complete this form to transfer funds by wire to a non-U.S. bank.

Wire Transfer Services Application And Agreement (Deposit Accounts Only)
In order for Bank customers with commercial or trust deposit accounts to transfer funds by wire to another bank, this form must be on file with The Bancorp Bank. Please complete and return the form to The Bancorp Bank before initiating your first wire transfer request (return contact information is provided on the last page of the Agreement; you only need to complete the form once). From the date we receive the completed form, please allow at least two business days before initiating your first wire transfer request. A Caller ID and PIN will be issued to each authorized representative by secure email or by mail. Please sign and return the PIN Acknowledgement Form to activate security credentials (Caller ID and PIN) in order to initiate a wire transfer request via fax, mail, or telephone.

Note: If you are an owner of an individual/joint account, you should not complete this form, unless to provide authorization of a third party, such as a financial professional, to send wires on your behalf.

Wire Instructions - Incoming
For an incoming wire transfer to your The Bancorp Bank account from a U.S. or non-U.S. bank.

Wire Instructions - Outgoing
For an outgoing wire transfer from your The Bancorp Bank account to a U.S. or non-U.S. bank.

W-8BEN Form
This form must be completed by a non-U.S. resident or business owner who does not have a U.S. Social Security Number (SSN) or Tax Identification Number (TIN).