Employee Enrollment Form
Step1:
Tell us information about the employee.
Name of Business or Proprietor:
Business ID#:
(existing clients only)
Name of employee or Proprietor:
Mr.
Mrs.
Miss
Ms.
Dr.
Employee ID#
(existing clients only)
Benefit Cheque To Be Sent To:
Business Address
Home Address
Home Address:
City:
Province:
Select a Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavit
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code:
Business Address:
City:
Province:
Select a Province
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavit
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon
Postal Code:
Day Time Phone Number:
(Including area code)
Fax Number:
(Including area code)
E-mail Address:
Step2:
Action Requested.
Add employee and family members to plan
Delete employee and family members from plan
Add spouse and/or child to plan
Delete spouse and/or child from plan
Effective Date of Action:
Select a Month
January
February
March
April
May
June
July
August
September
October
November
December
Select a Year
2007
2008
Step3:
Tell us immediate family members enrollment information.
A child is eligible only if financially dependent upon the Employee and/or Spouse.
IMMEDIATE FAMILY MEMBERS
Immediate Family members
Full
Given Name
Surname
(if different from employee's surname)
Sex
Date Of Birth
(yyyymmdd)
Employee
Male
Female
Spouse
Male
Female
1
st
child
Male
Female
2
nd
child
Male
Female
3
rd
child
Male
Female
4
th
child
Male
Female
5
th
child
Male
Female
6
th
child
Male
Female
Comments:
Site developed by Susan Chen Associates
