Company Enrolment Form

For employees of existing clients, click here to enrol.

*Fields marked with asterisks are required.

Enrolment type*:

Incorporated companyEmployee (with updates to company)Sole proprietor (unincorporated company with employees)

Company name*:

Year end*:

Company physical address*:

City*:

Province*:

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:

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.

Name:

Relationship:

Birth date:

Name:

Relationship:

Birth date:

Name:

Relationship:

Birth date:

Name:

Relationship:

Birth date:

Name:

Relationship:

Birth date:

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.

Agreement Terms

Eligible under the Tax Regulations:

Under current CRA tax regulations, incorporated businesses and eligible sole proprietors can use the services of a third party administrator to “HealthLink Benefits” eligible medical expenses as defined in The Income Tax Act.

Terms

Coverage: The plan covers, for the people listed on the enrolment form, all hospital, medical and dental expenses that qualify as such expenses under the Income Tax Act of Canada (ITA) and are not prohibited by law.
Claim Submission, Approval and Payment: The Policyholder shall submit receipts and payment for all claims listed plus the administration fee and applicable tax. The Administrator (HealthLink Benefits), on receipt of a claim from the employee of the Policyholder, shall determine whether the claim is for an expense covered by the plan. The Administrator shall issue payment for the eligible claim directly to the individual listed on the enrolment form and shall provide notification of such payment to Policyholder if they are not the same.
Consent to Communicate by E-Mail: The Policyholder, by providing the email address requested above, hereby gives consent under Canada’s anti-spam legislation (CASL) to HealthLink Benefits to send information relevant to our business relationship, including but not limited to reminders, announcements and clarification of claims and other information about our services. You have the ability to withdraw your consent at any time.
General: The laws in force in Ontario govern this agreement. If any provision of this agreement is changed by the Federal or Provincial Government, this will affect the agreement of this form.

Please provide a void cheque for banking information to set up electronic payment of reimbursement to your personal account.