Enrolment type*:

Company name*:

Year end*:
JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember

Company physical address*:

City*:

Province*:
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

Postal code*:

Click here if your company's mailing address is different to its physical address.

Telephone*:

Fax:*

Contact person*:

E-mail address*:

Accountant:

Referred by:

Is your company a member of the Alberta Dental Association?
YesNo

Employee details

Name*:

Are you the company owner?
YesNo

Date of birth:

Home address:

City:

Province:
AlbertaBritish ColumbiaManitobaNew BrunswickNewfoundland and LabradorNorthwest TerritoriesNova ScotiaNunavutOntarioPrince Edward IslandQuebecSaskatchewanYukon

E-mail address:

Telephone:

Cellphone:

Listing of Dependents:

Please list all dependents who will be covered under this plan.

Dependents of an Eligible Employee are defined as follows:

• A spouse who is either legally married to employee or who is living with the employee and is publicly represented as the Employee's spouse; OR

• Any member of the employee's household with whom the employee is connected by blood relationship, marriage or adoption; OR

• Children over age 18 who are attending school full time

Confirmation

I wish to participate in the Private Health Service Plan provided by Cost Efficient Benefit Plan.

Date*:

Employee name*:

Employer approval:

Eligibility Effective Date*:

Employer name*:

I confirm that the above information is correct, and I have read and accept the terms of the attached agreement.

Check the box to accept the terms*:

One time enrolment fee: $100 plus provincial taxes.

Employee enrolment fee: No charge.

Please ensure all fields marked with an asterisk have been filled in.
This form will be e-mailed to you. If you would like to print the form, we recommend printing the e-mail.

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