Employee Enrolment Name Today's Date * Date of Hire * Date of Coverage * Company Name * Business Phone # * Employee Category * for determination of employee credits coverage 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 City * Employee Name * Smoker Smoker Non-smoker Sex * Male Female Date of Birth * 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 E-mail Address * Your e-mail is required to receive your account balance and other important information Primary Phone * Secondary Phone I have attached a void cheque or bank stamped personal savings account information for Electronic Claim Payment * Yes No Electronic Claim Payment Attachment 1. Does Your Spouse Have Group Coverage? * Yes No if yes, please submit claims to your spouse's insurance plan first 2. Do you or your dependants have regular monthly Rx Prescription Drug costs? * Yes No 3. Do you or your dependants visit a dentist office twice a year? * Yes No if yes, then consider dental extra credits 4. Would you like to receive employee information on optional Mortgage, Life & Critical Illness insurance options Yes No Agree * Yes, I Agree I have reviewed the above information and sign off on the accuracy of adjustment, additions or removal of Health & Dental Benefits Todays Date *
