Enrolment Form — Detailed

Company Name
Address
City
Province
Postal Code
Phone
Fax
Email
Contact Name

Annual medical expenditure limits for:

Single

Family

Dependents (I.e. Spouse, children enroled in full time school under the age of 25)
Grandparents

Define how many different limits you would like:

If all employees are to receive the same coverage, please fill in information for group 1.

If different groups of employees are to receive different levels of coverage, please fill in information for 2 or 3 groups.

1 group (each employee has the same coverage)

$ per contract year per employee/family for allowable medical and dental expenses
(i.e. $1,000 max per contract year)

employees in that group

2 groups (Two groups of employees with different coverage)

$ per contract year per employee/family for allowable medical and dental expenses
(i.e. $1,000 max per contract year)

employees in that group

$ per contract year per employee/family for allowable medical and dental expenses
(i.e. $1,000 max per contract year)

employees in that group

3 groups (Two groups of employees with different coverage)

$ per contract year per employee/family for allowable medical and dental expenses
(i.e. $1,000 max per contract year)

employees in that group

$ per contract year per employee/family for allowable medical and dental expenses
(i.e. $1,000 max per contract year)

employees in that group

$ per contract year per employee/family for allowable medical and dental expenses
(i.e. $1,000 max per contract year)

employees in that group

Medical coverage includes (amounts are including taxes)

Limits can be placed on treatments such as:

i.e. 80% on prescriptions or max $300 per contract year

Treatment	% Max	OR	$ Max
Prescriptions
Chiropodist/ Podiatrist
Orthopedic Shoes
Dietician
Optometrist
Eye glasses, contact lenses
Registered Massage Therapist
Occupational Therapist
Psychologist / Psychotherapist
Naturopathic Doctor
Physiotherapists
Acupuncture
Other medical services
Treatment	% Max	OR	$ Max



Dental coverage includes
Treatment	% Max	OR	$ Max
Diagnostic
Preventive Services
Restorative
Orthodontist

Roll forward unused annual limit to next contract period

Yes

Apply to all employees in all groups or
Selective groups (I.e. Group 1)

No

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