Employer Application Form

tax deduction 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
Business Address:
Postal Code:
Contact Person:
  Mr. Mrs. Miss Ms. Dr.
Position Title:
Phone Number:
(including area code)
Fax Number:
(including area code)
E-mail Address:
tax deduction Step2: Tell us information about your business.
Fiscal Period for Income Tax Receipts:
Describe Your Business:
tax deduction Step3: Tell us information about your self directed plan.
Requested Effective Date:
tax deduction 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
Please Specify If Other Is Selected:
Number Of Eligible Employees:
tax deduction Step5: Tell us what benefits you want to have in your plan.
benefit plan If you wish to cover all health and dental check off "All Dental" and "All Health" with "Full Coverage" for each one.
benefit plan Otherwise, check off only the benefits you want to cover.
benefit plan 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 .
benefit plan 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.
Dental Full
Annual Deductible Reimburse Percentage Annual Maximum
All Dental
Preventative, diagnostic and minor restorative
Endodontics and periodontics
Major restorative
Health Full
Annual Deductible Reimburse Percentage Annual Maximum
All Health
Prescription drugs
Semi-private hospital accommodations
Private hospital accommodations
Vision benefit
All other eligible health benefits
tax deduction 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
If the above chart is left blank we will assume you do not want any overall amount maximum.
tax deduction Step7: Tell us whether you want worldwide coverage or coverage only in Canada.
benefit plan Select world coverage and your business may be liable for huge medical claims abroad.
benefit plan 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.
Canada only
Worldwide (Not recommended due to large potential medical costs)
Canada only plus travel medical insurance premiums (Recommended)

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