Health Savings Account Application

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You are entitled by law to receive certain information in writing. The federal E-SIGN Act allows us to provide this information to you electronically with your consent. Before you obtain products and services through the online application or enrollment, you must review and consent to the terms outlined below:

Your Consent to Use Electronic Records

We may at our sole option provide agreements, disclosures, notices, records, and other information in electronic form ("Electronic Records") that we are legally required to provide to you in connection with your online application and online and mobile banking enrollment. If you do not want to receive this information as Electronic Records, you should exit this area of the website, and contact us in person or by phone. If you do not consent to receiving the Electronic Records, you will not be able to apply for an account or enroll in online and mobile banking via this website.

Your Option to Receive Paper Copies

If we provide you with Electronic Records and you want a copy in paper, you may print or download a copy from this site or contact us by e-mail or by phone to submit a request for paper copies. You may be subject to a fee for your request unless prohibited by applicable law.

Withdrawal of Consent

You have the right to withdraw your consent at any time at no cost to you by contacting us by e-mail or by phone.

Contact Information

You must provide us with accurate contact information as part of your online application and online and mobile banking enrollment. If you later need to update your information please contact us by e-mail or by phone, or you may update your contact information via Online Banking.

Hardware and Software You Will Need

In order to receive these disclosures in electronic form, you will need an internet connection and a web browser such as Microsoft Internet Explorer, Mozilla Firefox, or Google Chrome, and a PDF reader, such as Adobe® Reader®. By consenting to this E-Sign Disclosure and Consent, you indicate your ability to receive Electronic Records in electronic form.

C340-184DEPNT (3/18)

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Important information about procedures for opening a new account

To help the government fight the funding of terrorism and money laundering activities, Federal law requires all financial institutions to obtain, verify, and record information that identifies each person who opens an account.

What this means for you:

  • When you open an account, we will ask for your name, address, date of birth and other information that will allow us to identify you.
  • We may also ask to see your driver’s license or other identifying documents.

Customer identity verification

Under the USA PATRIOT Act, we are obligated to verify the identity of each customer opening a new account, or each new owner being added to a deposit account. In addition, we are obligated to obtain sufficient information to establish the intended purpose of each deposit account. Customer understands and agrees that if INTRUST is not able to verify the identity of all of the owners and the purpose of the account within a reasonable time, we may, at any time, in our sole discretion, without providing advance notice, close the account.

C340-131 (3/18)

Information About Yourself (Primary Signer)

PLEASE NOTE: All applicants must be (1) a U.S. Citizen or Permanent U.S. Resident; AND (2) a resident of Kansas, Oklahoma, Missouri, or an existing INTRUST customer to apply for a new account online. You will incur an account set up fee at the time this account is established which will be deducted from your account balance.

(MM/DD/YYYY)


(if less than 3 years at current address)
(By providing your email address, you agree that we may use it to deliver information about your account or promotional information to you. You may opt-out of receiving promotional emails; however, a valid email address is required to deliver account related information electronically. Additionally, the email address provided here will automatically update the email address used in Personal Online Banking.)

Employment Information

(company name)

B700-90NT (11/15)

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Account Designations


Power of Attorney (POA) Election
Power of Attorney (POA) Election

POA Election 1

(MM/DD/YYYY)

POA Election 2

(MM/DD/YYYY)

POA Election 3

(MM/DD/YYYY)
Contribution Type
Contribution Type
(MM/DD/YYYY)

Individual Opening Contribution

(dollar amount without decimal and cents)

Note: This account is designed for payment of qualified medical expenses. Purchases made with either the debit card or checks will be reported by the Bank at year-end as qualified distributions from the account. I am aware that neither I nor my POA, if any, should use the debit card or checks for non-qualifying or non-medical purposes and am personally responsible for any IRS penalties or taxes that may apply.

B700-90NT (11/15)

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At the time of my death, the primary beneficiaries named below will receive my HSA. If all of my primary beneficiaries die before me, the contingent beneficiaries named below will receive my HSA assets. In the event a beneficiary dies before me, such beneficiary’s share will be reallocated on a pro-rata basis to the other beneficiaries that share the deceased beneficiary’s classification as a primary or contingent beneficiary. In the event a beneficiary is named as both a primary and contingent beneficiary, such beneficiary shall be a primary beneficiary. If no percentages are assigned to beneficiaries, or if the percentage total for any beneficiary classification exceeds 100 percent, the beneficiaries in that beneficiary classification will share equally. If the percentage total for each beneficiary classification is less than 100 percent, any remaining percentage will be divided equally among the beneficiaries within such class. If all of the beneficiaries die before me, or if none are designated, my HSA assets will be paid to my estate. This designation revokes and supercedes all earlier beneficiary designation which may apply to this HSA.

Primary Beneficiaries

The total percentage of all "Primary" beneficiaries designated below should equal 100%.

Primary 1

(MM/DD/YYYY)

Primary 2

(MM/DD/YYYY)

Primary 3

(MM/DD/YYYY)

Contingent Beneficiaries

The total percentage of all "Contingent" beneficiaries designated below should equal 100%.

Contingent 1

(MM/DD/YYYY)

Contingent 2

(MM/DD/YYYY)

Contingent 3

(MM/DD/YYYY)

B700-90NT (11/15)

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Please review your information to ensure that it's correct, then click "Previous" or "Next".

Information About Yourself (Primary Signer)

Full Name
Date of Birth
Social Security Number
Street Address
City and State
ZIP code
Years at Residence
US Citizen
Permanent Resident
Home Phone
Previous Address
Mother's Maiden Name
E-mail Address

Employment Information

Employer
Employer Address
Occupation / Position
Work Phone
Extension

Account Designations

Type of Health Insurance Plan Coverage
Power of Attorney (POA) Election

POA Election 1

Name of POA
Social Security Number
Date of Birth
Street Address
City
State
ZIP code

POA Election 2

Name of POA
Social Security Number
Date of Birth
Street Address
City
State
ZIP code

POA Election 3

Name of POA
Social Security Number
Date of Birth
Street Address
City
State
ZIP code
Contribution Type
Contribution Date
Amount
Tax Year

Primary Beneficiaries

Primary 1

Percentage
Name of Beneficiary
Social Security or Taxpayer Identification Number
Date of Birth
Street Address
City
State
ZIP code
Relationship to HSA Owner

Primary 2

Percentage
Name of Beneficiary
Social Security or Taxpayer Identification Number
Date of Birth
Street Address
City
State
ZIP code
Relationship to HSA Owner

Primary 3

Percentage
Name of Beneficiary
Social Security or Taxpayer Identification Number
Date of Birth
Street Address
City
State
ZIP code
Relationship to HSA Owner

Contingent Beneficiaries

Contingent 1

Percentage
Name of Beneficiary
Social Security or Taxpayer Identification Number
Date of Birth
Street Address
City
State
ZIP code
Relationship to HSA Owner

Contingent 2

Percentage
Name of Beneficiary
Social Security or Taxpayer Identification Number
Date of Birth
Street Address
City
State
ZIP code
Relationship to HSA Owner

Contingent 3

Percentage
Name of Beneficiary
Social Security or Taxpayer Identification Number
Date of Birth
Street Address
City
State
ZIP code
Relationship to HSA Owner

B700-90NT (11/15)

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Disclosures

The following disclosures provide important information regarding the account for which you're applying. To proceed with your application, please read and accept each disclosure, and then click "Submit" below.

HSA Truth in Savings Disclosure

Thank you for choosing INTRUST Bank, N.A.! This disclosure offers an overview of our Health Savings Account. The overview includes balance and interest rate information.

Rate Information: Interest will be calculated on the daily collected balance in your account. Interest will be based on tiers; only one tier of interest will be applied to your account per day. The collected balance in your account will determine which tier of interest will be used to calculate your interest for that day. Interest will be compounded and credited to your account on a monthly basis. The interest rate and annual percentage yield tiers for this account are found on the INTRUST Health Savings Account Rates & Fees page.

Variable Rates: This account earns a variable rate of interest; the interest rate and annual percentage yield may change. At our discretion, INTRUST Bank may change the interest rate on each tier, thereby changing the annual percentage yield at any time.

Minimum Balance Requirements: There is a monthly cycle account maintenance fee of $2.50. Avoid the monthly cycle account maintenance fee by maintaining an average collected balance of $1,000 in this account per monthly cycle.

Fees: There is an account set up fee of $15. Refer to the current Personal Accounts Fee Schedule for a listing of fees that may be assessed.

Prior Notice of Withdrawal: We may require you to give us seven (7) days written notice of your intent to withdraw money from your account. This notice would be a precondition to the withdrawal of any sum of money. By permitting withdrawals without notice, we do not waive our right to require such notice.

Service Charge Fee: Total monthly cycle service charge is the sum of the account maintenance fee, other service charge fees and activity fees. The account maintenance fee will be waived for one monthly cycle after opening this account.

Account Closing: If you close your account before interest is credited, you will not receive the accrued interest.

Non-cash Deposits: When you deposit a non-cash item (i.e. check), interest, if applicable, begins to accrue no later than the business day we receive credit for the deposit.

Balance Computation Method: We use the daily balance method to calculate the interest on your account. This method applies the daily periodic rate to the principal in the account each day.

Average Collected Balance: The average collected balance is calculated by adding the collected principal in the account for each day of the period and dividing the figure by the number of days in the period.

Month: An approximate four (4) week period or cycle, not necessarily a calendar month.

Monthly Cycle Data: Date on which the monthly cycle ends and a statement is created. In most cases, monthly service charge fees are assessed on the monthly cycle date.

B700-89NT (10/26/15)

Electronic Fund Transfers Disclosure

ELECTRONIC FUND TRANSFERS DISCLOSURE

As a customer of INTRUST Bank, N.A. you may have been issued an INTRUST ATM Card, INTRUST Visa® Debit Card, or INTRUST HSA Visa Debit Card (all referred to as "Card"). You may be taking advantage of other electronic banking services we offer which require a code or other means of access to initiate an electronic fund transfer. Cards, codes and other means of access to initiate an electronic fund transfer are all referred to as "Access Device" and are subject to the Electronic Fund Transfers Act. Personal Identification Number (PIN) or Personal Security Code (PSC) or Password or Log-In Identification or any other security devices as may be specified by the Bank for secured access and Account Identification Number are all included in any reference to "Access Device" in this disclosure. The following disclosures, some of which may not apply to your particular situation, are required to be given. To obtain agreements for Online Bill Pay, Automated Telephone Transfer, Online Banking and Mobile Banking, External Transfer, Personal Financial Manager Bill Pay, or People Pay including the Electronic Fund Transfers Disclosure, please visit www.intrustbank.com, the INTRUST location nearest you, or call the INTRUST Customer Solutions Center at 316-383-1234 or 800-895-2265.

  1. Your liability for unauthorized transfers. Tell us AT ONCE if you believe your Access Device has been lost or stolen or if you believe that an electronic fund transfer has been made without your permission using information from your check. Telephoning is the best way of keeping your possible losses down. You could lose all the money in your account (plus any available overdraft protection). If you notify us within 2 business days after you learn of the loss or theft or your Access Device, you can lose no more than $50 if someone used your Access Device without your permission. If you fail to notify us within 2 business days after learning of the loss or theft of your Access Device, you can lose no more than $500.

    Also, if your statement shows transfers that you did not make, tell us at once. If you do not notify us in writing within 60 calendar days after the statement was mailed to you, you may not get back any money you lost after the 60 days if we can prove that we could have stopped someone from taking the money if you had told us in time. If a good reason (such as a long trip or a hospital stay) kept you from telling us, we will extend the time periods.

  2. Contact in event of unauthorized transfers. If you believe your Access Device has been lost or stolen or that someone has transferred or may transfer money from your account without your permission, call us 24 hours a day or write:

    316-383-1354 or 800-222-7458
    INTRUST Card Security
    P.O. Box 2121
    Wichita, Kansas 67201

  3. Business days. For purposes of these disclosures, our business days are Monday through Friday. Saturdays, Sundays, and holidays are not included.

  4. Types of transfers and limitations.

    1. Account access1. You may use your Access Device to:
      1. Withdraw cash from your checking, savings, or money market account.
      2. Make deposits to your checking, savings, or money market account. All deposits are subject to next day verification.
      3. Transfer funds between your checking, savings, or money market account.2
      4. Make balance inquiries.
      5. Pay for purchases at places which have agreed to accept our Cards.
    2. Preauthorized transfers. We are equipped to:
      1. Accept certain direct deposits to your checking, savings, or money market account.
      2. Accept certain transfers from your checking, savings, or money market account.
      3. Pay certain bills from your checking account.
    3. Electronic check conversion. You may authorize a merchant or other payee to make a one-time electronic payment from your checking account using information from your check to:
      1. Pay for purchases; or
      2. Pay bills.
    4. Limitations on frequency of transfers.
      1. According to federal law, transfers from a money market deposit account or savings account to another account or to third parties by preauthorized, automatic, or telephone transfer are limited to six (6) per monthly3 cycle. Each transaction in excess of the limit will be charged $10 in addition to other fees and charges.
      2. There is a limit of five (5) cash withdrawals from automated teller machines (referred to as "ATM") or cash dispensing machines per day. There is a limit of fifteen (15) Card purchases per day. These limits may not be in effect at all times. We may impose additional limitations without prior notice if necessary to maintain the security of your account or our processing system.
    5. Limitations on dollar amount of transfers.
      1. At an ATM or cash dispensing machine, each day you may withdraw up to your available account balance or the daily withdrawal limit, whichever is less. For daily Card purchases, you may withdraw up to your available account balance or the daily limit, whichever is less. Limits may not be in effect at all times. INTRUST may impose limits, at its discretion, without prior notice. Limits may vary by product, or location, or account type, or device, or combination thereof to maintain the security of your account or our processing system.
      2. INTRUST may impose limitations on the frequency and dollar amount for your use of External Transfers, Mobile Check Deposit, Online Bill Pay and People Pay (Digital Product). INTRUST may, at its discretion, increase or decrease these limits or impose additional limitations without prior notice to maintain the security of your account or our processing system. Examples of limitations that INTRUST may impose include, but are not limited to:
        1. Customer;
        2. Transaction;
        3. Frequency;
        4. Digital Product;
        5. Account type;
        6. Device; or
        7. Any combination therof
    6. Disclosure of account balances at non-INTRUST ATMs. Account balances provided at an ATM that is not an INTRUST ATM do not include available Bounce Blocker or other Overdraft Protection product funds. However, INTRUST may authorize and complete transactions by drawing on any Bounce Blocker or other Overdraft Protection product funds which may be available without prior notice to you.

  5. Fees for transfers2 Each time you use your Card at an ATM that is not an INTRUST ATM, your account will be charged $2 for each transfer (transfer includes any balance inquiry) unless you have an INTRUST Elite Checking account4, or an INTRUST Advantage Checking account5, or an INTRUST Employee Checking account5.

    Optional Account Features6: Personal Financial Manager Bill Pay (e.g., Quicken® Banking) is $5 per month, including 10 bill payments. Each additional bill payment is $0.50. QuickBooks® is $10 per month, including 20 bill payments. Each additional bill payment is $0.50.

  6. Confidentiality. We will disclose information to third parties about account transfers you make:

    1. Where it is necessary for completing a transfer;
    2. In order to verify the existence and condition of your account to a third party, such as a credit bureau or merchant;
    3. In order to comply with a governmental agency or court order; or
    4. If you give us your written permission.

  7. Documentation of transfers.

    1. Terminal transfers. As required by law, you will receive a receipt at the time you make any transfer to or from your account using one of our Terminals. ("Terminal" includes ATMs or point of sale terminals and cash dispensing machines). Federal law does not require a receipt for transactions of $15 or less.
    2. Preauthorized credits. If you have arranged to have direct deposits made to your account at least once every 60 days from the same person or company, you can call us at 316-383-1234 to find out if the deposit has been made.
    3. Periodic statements. You will receive a monthly3 statement unless there are no transfers in a particular month3. In any case, you will get a statement at least quarterly. Your statement is deemed delivered to you on the date we place it in the mail, transmit it electronically, or if we do not have a current address, when prepared by us.

  8. Preauthorized transfers.2

    1. Electronic Transfers.
      1. Right to stop payment and procedure for doing so. If you have told us in advance to make regular payments out of your account, you can stop any of those payments as follows:
        Call us at:316-383-1234 or 800-895-2265; or
        Write us at: INTRUST Bank, N.A.
        Customer Service Center
        P.O. Box 847
        Wichita, Kansas 67201
        in time for us to receive your request 3 business days or more before the payment is scheduled to be made. If you call, we may also require you to put your request in writing and get it to us within 14 days after you have called us. We will charge you a fee for each stop payment order you give us orally or in writing. Please refer to the Personal Accounts Fee Schedule for the amount of this fee.
      2. Notice of varying amounts. If these regular payments may vary in amount, the person you are going to pay will tell you 10 days before each payment when it will be made and how much it will be. You may choose instead to get this notice only when the payment would differ by more than a certain amount from the previous payment, or when the amount would fall outside certain limits you set.
      3. Liability for failure to stop payment of preauthorized transfer. If you order us to stop one of these payments 3 business days or more before the transfer is scheduled, and we do not do so, we will be liable for your losses or damages.
    2. Online Bill Pay.
      1. Right to stop payment and procedure for doing so on a paper check.
        1. You may request a stop payment be placed on an Online Bill Pay paper check by contacting Customer Service at 800-999-4048 or at 316-383-1340. No stop payment will be placed if the check has already been presented for payment.
        2. If you request a stop payment on a repeating payment, it will not affect future repeating payments unless you enter new payment instructions on Online Bill Pay.
      2. Right to stop payment and procedure for doing so on an electronic payment.
        1. No stop payment can be placed after the cutoff time on the payment date.
    3. External Transfers.
      1. No stop payment can be placed. You may edit or revoke a transfer instruction prior to the business day cutoff on the date the transfer is scheduled to occur.

  9. Our liability to you. If we do not complete a transfer to or from your account on time or in the correct amount according to our agreement with you, we will be liable for your losses and damages. However, there are some exceptions. We will NOT be liable, for instance, if:

    1. Through no fault of ours, you do not have enough money in your account to make the transfer.
    2. The transfer would go over the credit limit on your overdraft line.
    3. The ATM or cash dispensing machine where you are making the transfer does not have enough cash.
    4. The Terminal and/or system was not working properly and you knew about the malfunction when you started the transfer.
    5. Circumstances beyond our control (such as acts of God, fire, or flood) prevent the transfer despite reasonable precautions that we have taken.
    6. Bank is prohibited by law from completing the transaction.
    7. There may be other exceptions stated in our agreements with you.

  10. ATM fees.

    1. When you use an ATM not owned by us, you may be charged a fee by the ATM operator or any network used and you may be charged for a balance inquiry even if you do not complete a fund transfer unless you have an INTRUST Elite Checking account7, or an INTRUST Advantage Checking account8, or an INTRUST Employee Checking account8.

  11. Error resolution. In case of errors or questions about your electronic transfers, telephone us at 316-383-1354 or 800-222-7458, or write us at P.O. Box 2121, Wichita, Kansas 67201, as soon as you can, if you think your statement or receipt is wrong or if you need more information about a transfer listed on the statement or receipt. We must hear from you no later than 60 days after we send the FIRST statement on which the problem or error appears.

    1. Tell us your name and account number, if any.
    2. Describe the error or transfer you are unsure about and explain as clearly as you can why you believe it is an error or why you need more information.
    3. Tell us the dollar amount of the suspected error.
    If you tell us orally, we may require that you send us your complaint or question in writing within 10 business days.

    We will tell you the results of our investigation within 10 business days after we hear from you and will correct any error promptly. If we need more time, however, we may take up to 45 days to investigate your complaint or question. If we decide to do this, we will recredit your account within 10 business days for the amount you think is in error, so that you will have the use of the money during the time it takes us to complete our investigation. If we ask you to put your complaint or question in writing and we do not receive it within 10 business days, we may not recredit your account.

    For errors involving new accounts (within 30 days after the first deposit), point of sale transactions made with a Card, or foreign-initiated transactions, we may take up to 90 days to investigate your complaint or question. For new accounts, we may take up to 20 business days to credit your account for the amount you think is in error.

    We will tell you the results within 3 business days after completing our investigation. If we decide that there was no error, we will send you a written explanation and remove any recredited amount from your account. You may ask for copies of the documents that we used in our investigation.

1 Some services may not be available at all Terminals.
2 Not available for Health Savings Accounts.
3 An approximate four (4) week period or cycle, not necessarily a calendar month.
4 INTRUST Elite Checking will receive a refund (credit) for INTRUST ATM transaction fees each statement period, at the time of transaction, that INTRUST Bank would normally charge for your use of an ATM owned by another institution.
5 INTRUST Advantage Checking and Employee Checking accounts will receive a refund up to $6 in non-INTRUST ATM transaction fees each statement period. These fees will be refunded to your account as a lump sum at the end of the statement period.
6 Not applicable for INTRUST Elite Checking accounts.
7 INTRUST Elite Checking will receive a rebate for charges imposed by other financial institutions for your use of their ATMs. All rebates credited to your account for these ATM fees will be reported to the IRS as interest earned. Your average collected account balance must be equal to or greater than zero ($0) at the time of the ATM transaction to receive the fee rebate.
8 INTRUST Advantage Checking or Employee Checking will receive a rebate of up to $6 for charges imposed by other financial institutions for your use of their ATMs. These fees will be credited to your account as a lump sum at the end of the statement period. All refunds credited to your account for these ATM fees will be reported to the IRS as interest earned. These fees will be rebated only if the average collected account balance in your account is equal to or greater than zero ($0) one business day prior to the last business day of the account’s statement period.

Member FDIC

C340-106NT (5/23/2017)

Privacy Policy

Government regulations require that we provide certain account information and agreements to you when you apply for an account with INTRUST Bank, NA. The DEPOSIT AGREEMENT contains information that is pertinent to how we service your banking needs on a daily basis, such as direct deposits, "stop payment" instructions, our right to return any item unpaid on your account, and more.

Note: Your account is not instantly opened after applying online. In order to formally open your account, you must complete and return the packet you will receive in the mail upon completion of the online application. Your account cannot be opened until we receive these items. If you're opening your first account with INTRUST, additional items will be requested.

Submission of this Application and completion and execution of other documents including the signature card, does not constitute approval or acceptance of the HSA by the Bank. If your HSA is approved by the Bank, you will incur an "Account Set Up" fee, which will be deducted from your account balance.

You certify that (1) You are or will be covered by a qualified High Deductible Health Plan (HDHP), (2) You certify that you are not covered by a health plan, other than an HDHP, which provides any of the same benefits as the HDHP, (3) You are not entitled to benefits under Medicare, and (4) You may not be claimed as a dependant on another person's tax return.

You authorize the Bank to release to your employer the account number of your HSA for the purpose of making contributions to the account on your behalf. The release of this information does not constitute any violation of your right to privacy of such information by the Bank.

You agree to the terms and conditions of the INTRUST Cardholder Agreement for Consumer Visa® Debit Card, Health Savings Account Visa Debit Card, Wealth Checking Visa Debit Card, Business Visa Debit Card and ATM Card that you will receive with your debit card.

You certify that the information provided on this application is correct and you authorize the Bank to verify such information and to make such other investigations, which will include obtaining a credit report on you. You understand the Bank will also use the credit report to determine your suitability for the Bank's debit card product, a credit card and/or a personal loan, which may result in the Bank (1) providing you an application, or (2) later providing you a pre-approved offer for some or all of those products. If you receive an application, it does not constitute pre-approval for the product. You understand you may complete applications for debit card, credit card and personal loan products at any time. The Bank may refuse to open, or may later close, this account if any of the information is incorrect or cannot be verified, or your credit report contains information the Bank deems to not meet its standards.

B700-90NT (11/15)

Thank you for opening your new account with INTRUST Bank!

We'll begin processing your application now, but before your account can be formally opened and you can receive your account number, we must also receive your completed information packet which we are mailing to the address you listed in your application.

  1. Once you receive the information packet, please review and sign the application and additional forms.
  2. If you are opening your first account with INTRUST, in addition to the completed information packet, please mail a copy of your current, valid photo ID and a copy of your most recent utility bill displaying your current address.
  3. Return the completed information packet to INTRUST in the envelope included.
  4. Subject to approval, you will receive your account information from us by mail within 3-5 business days after we receive your completed information packet.

Questions? Contact Customer Service.

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B700-90NT (11/15)

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