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Administrator's Fee: 5% OF ALL CLAIMS SUBMITTED (GST on Admin fee Extra) plus a $10.00 processing charge.*

First Name *

Last Name *

Title

COMPANY NAME *

Address 1 *

City *

Province *

Postal Code *

Business Phone *

Fax

Email Address *

Email Address to be used for APP user name: *

Benefits Administrator: *

Same as above

No- name and email provided here

IF NO, Administrator email:

Administrator Name:

Please use our Employee Enrollment Form for each added user.

Yes, we have additional employees/users to be added to the plan.

+ PLAN START DATE: The Administrator and business owner agree to establish and administer the Private Health Services Plan ("Plan") on the terms specified below, effective as of this date:

TERMS

1. The Plan covers all hospital, medical and dental expenses of the Insured ("Claims") that: qualify as such expenses under the Income Tax Act of Canada ("ITA"); are not prohibited by law; and are approved and submitted by the Corporation or business owner.

2. The Corporation or business owner shall submit full payment with claims.

3. CLAIM APPROVAL AND SUBMISSION: All claims submitted to the Administrator shall be deemed to have been approved by the Corporation or business owner and the Administrator shall be under no further obligation to confirm such status.

4. CLAIMS AND FEE PAYMENT: Upon receipt of the Claim, the Administrator shall issue payment for the Claim by cheque or direct deposit directly to the individual claimant and shall provide notification of such payment to the Corporation or business owner.

5.INDEMNITY: Should the Corporation or business owner request the Administrator to pay a Claim for which there are not sufficient Contributions on deposit to the Corporation or business owner’s credit and should the Administrator agree, at its sole option, to make such payment, the Corporation or business owner shall: be liable for; and indemnify and save harmless the Administrator from all manners of action, causes of action, damages or expenses whatsoever which may be brought or made against the Administrator as a result of making such payment and to the Administrator for such payment and the Fee.

6. TERMINATION PRIOR TO THE TERM DATE: The Administrator or Corporation or business owner may terminate this Agreement on 30 calendar days' written notice to the other at the address indicated.

7. TAX TREATMENT: The characterization of the Contributions and the Claims paid under the ITA is a matter to be assessed solely by the Corporation or business owner and the Administrator.

8. GENERAL: Time is important. This Agreement is governed by the laws in force in Canada. If any provision of this Agreement is found by a court of competent jurisdiction to be unenforceable then such provision shall be severed and the remaining terms and covenants shall be unaffected and enforced to the greatest extent permitted by law. No amendment of the Agreement shall be valid unless in writing and signed by the Policyholder and the Administrator. Words importing the singular number include the plural and vice versa as required by the context. The Summary forms part of this Agreement.

Referred by:

Emailing this form constitutes Agreement to the Terms and Conditions of Corporate Care's Private Health Services Plans and Cost Plus Plans. I also agree to the following:
I will keep medical receipts on file for 7 years as per CRA guidelines.
All medical receipts submitted will only be those from my own families expenses, and only amounts never reimbursed by this plan or other plans will be submitted. *

Yes, I agree to the terms

Please type your initials here *

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