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Enrollment Form
Company Name:
*
Employee First Name:
*
Employee Last Name:
*
ID # or SIN #:
*
Login Name:
*
Password:
*
Confirm Password:
*
Employee Home Address:
*
City:
*
Province:
Please select one
Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland
Northwest Territories
Nova Scotia
Nunavut
Ontario
Prince Edward Island
Québec
Saskatchewan
Yukon
*
Postal Code:
*
E-mail:
*
Date of Birth:
(DD/MM/YYYY)
*
Gender:
Male
Female
*
Coverage
Single
Couple
Family
*
Effective Date of Benefits:
(DD/MM/YYYY)
*
Maximum Yearly Benefit Amount:
*
(Without dollar sign and comma separator, e.g.
12345.67
)
Reimbursement Percentage:
100%
80%
50%
Other
*
if other, please enter amount:
%
Dependant First Name
Dependant Last Name
Relationship
Male
Female
Date of Birth (DD/MM/YYYY)
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Please select one
Spouse
Common law partner
Son
Daughter
Dependant parent
Other dependant
Add out-of-province / catastrophic health (OOPCAT) coverage?
Y
N
OOP Coverage - $0 deductible / person
CAT Coverage - $1500 deductible / person
Monthly
Single
$10.00
Couple
$20.00
Family
$25.00
I understand that the Canada Revenue Agency requires that all unincorporated businesses have an element of insurance coverage along with their Private Health Service Plan (PHSP).
Winflex Health Solutions Inc. has offered me “Out-of-province / Catastrophic health (OOPCAT) coverage” as per their terms and pricing which are described on their website
www.winflex.ca
.
Comparable catastrophic and/or travel coverage is presently provided for me under another plan. I am aware that by opting out, I forfeit all rights to coverage and I will not be able to apply for “Out-of-province / Catastrophic health (OOPCAT) coverage” coverage at a later date.
I have read and understand the above information. I wish to decline this valuable coverage
I have changed my mind and would like to opt in to this valuable coverage
Cancel
