Employee Enrolment Form

*Fields marked with asterisks are required.

Company details Company name*: City where company is based*: Company's province*: Contact person: Account number (if available): E-mail address to which your copy of this form will be sent*:

Employee details Name*: Date of birth: Home address: City: Province: Postal code: E-mail address: Telephone: Cellphone:

Listing of Dependents:

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

Name:

Relationship:

Birth date:

Add another dependent

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

Please upload your PERSONAL direct deposit information:

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*:

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.

This form has not yet been submitted.
If you require a paper copy of the submitted form, simply print the completed version which will be e-mailed to you upon clicking the Submit button.

Cost Efficient Benefit Plan
Tel: 403-282-3776 | Toll-free: 1-800-651-3776
E-mail: info@costplus.ca | Website: www.costplus.ca

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 "Cost Plus" 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 (Cost Efficient Benefit Plan), 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 Cost Efficient Benefit Plan 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 Alberta 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 personal void cheque to set up electronic payment of your reimbursement. Alternatively, a prefilled direct deposit form may be submitted. These can be downloaded from your online bank account.