Self Directed Plan Set - Employer Application Form

Employer Application Form

Step1:

Tell us the contact information of your business.

Name of Business or Proprietorship:

Business ID#:
(existing clients only)

Type of Business:

Corporation
Sole Proprietorship
Partnership

Business Address:

City:

Province:

Postal Code:

Contact Person:

Mr. Mrs. Miss Ms. Dr.

Position Title:

Phone Number:
(including area code)

Fax Number:
(including area code)

E-mail Address:

Step2:

Tell us information about your business.

Fiscal Period for Income Tax Receipts:

Describe Your Business:

Step3:

Tell us information about your self directed plan.

Requested Effective Date:

Step4:

Tell us who is eligible under your plan.

Class Of Employees To Be Eligible:

All employees
President and Vice Presidents
All non-seasonal employees working at least 30 hours per week
All non-union employees
Proprietor and all full-time employees
Other

Please Specify If Other Is Selected:

Number Of Eligible Employees:

Step5:

Tell us what benefits you want to have in your plan.

	If you wish to cover all health and dental check off "All Dental" and "All Health" with "Full Coverage" for each one.
	Otherwise, check off only the benefits you want to cover.
	You can choose to provide "Full Coverage" or to just cover a percentage of the cost or impose a deductible or maximum in your selected row(s) of the chart below .
	To do so, enter a percentage value in the "Reimbursement Percentage" column and/or a dollar amount in each of "Annual Deductible" and "Annual Maximum" columns.

BENEFIT PLAN SELECTIONS
Dental	Full Coverage	Annual Deductible	Reimburse Percentage	Annual Maximum
All Dental
Preventative, diagnostic and minor restorative
Endodontics and periodontics
Major restorative
Orthodontics
Other
Health	Full Coverage	Annual Deductible	Reimburse Percentage	Annual Maximum
All Health
Prescription drugs
Semi-private hospital accommodations
Private hospital accommodations
Vision benefit
All other eligible health benefits
Other

Step6:

Tell us what overall Annual Maximum per family type for all benefits combined you'd like to cover.

Overall Annual Maximum
Family Type	Amount
Single
Couple
Family

If the above chart is left blank we will assume you do not want any overall amount maximum.

Step7:

Tell us whether you want worldwide coverage or coverage only in Canada.

	Select world coverage and your business may be liable for huge medical claims abroad.
	Select the third option and your business will reimburse your employees for the premium they pay to an insurer for an Out of Country Medical Policy, but otherwise will not be responsible for any claims abroad.

Coverage
Canada only Worldwide (Not recommended due to large potential medical costs) Canada only plus travel medical insurance premiums (Recommended)

Comments:

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