EMPLOYEE ENROLMENT FORMFOR HEALTH & DENTAL ENROLMENT, POLICY CHANGES & TERMINATION Name Today's Date * Date of Hire * Date of Coverage * Employee Yearly Credits Company Name * Business Phone # * Employee Category for determination of employee credits coverage City * Province - Select Province/State - Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Nova Scotia Northwest Territories Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon ==================== Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Employee Name * Smoker Smoker Non-smoker Yearly Income * Sex * Male Female Date of Birth * Spouse Name Smoker Smoker Non-smoker Sex Male Female Date of Birth Status Add Change Remove Child Name Sex Male Female Date of Birth Status Add Change Remove Child Name 2 Sex Male Female Date of Birth Status Add Change Remove Child Name 3 Sex Male Female Date of Birth Status Add Change Remove E-mail Address * Your e-mail is required to receive your account balance and other important information I Agree * Yes, I Agree I agree that my email may be used to receive information regarding my benefits plan. This information will not be reused and will be kept confidential Primary Phone * Cell Phone I have attached a void cheque or bank stamped personal savings account information for Electronic Claim Payment * Yes No Electronic Claim Payment Attachment Does Your Spouse Have Group Coverage? * Yes No If yes, please submit claims to your spouse's insurance plan first Do you or your dependants have regular monthly Rx Prescription Drug costs? * Yes No Do you or your dependants visit a dentist office twice a year? * Yes No if yes, then consider extra dental credits at your-benefits.ca Yes I want to save money on my Mortgage, Life & Critical Illness Insurance. Please call me. Yes No Agree * Yes, I Agree I have reviewed the above information and signed off on the accuracy of adjustments, additions, or the removal of Health & Dental Benefits LOGIN TO OUR PORTAL LOGIN
