Enrollment Form

Company Name:
Employee First Name:
Employee Last Name:
ID # or SIN #:
Login Name:
Confirm Password:
Employee Home Address:
Postal Code:
Date of Birth:
  Male    Female *
   Single Couple Family *
Effective Date of Benefits:
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)

Add out-of-province / catastrophic health (OOPCAT) coverage?    Y   N
OOP Coverage - $0 deductible / person
CAT Coverage - $1500 deductible / person


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