Cost Efficient Benefit Plan Cost Efficient Benefit Plan
(Div. of Paloma Ventures Ltd.)
Mailing Address: 234, 5149 Country Hills Blvd. NW, Ste. 513 Calgary, Alberta T3A 5K8
Tel: 403-282-3776 Fax: 403-202-5046 Toll Free: 1-800-651-3776
Office Location: 216, 3907 - 3A Street NE, Calgary, AB (Do not mail to this address)
Edmonton, AB Tel: 780-377-1000 Toll Free: 1-855-575-5900
Okanagan, BC Toll Free: 1-844-498-0047
Cambridge, ON Toll Free: 1-866-965-2201
Website: www.costplus.ca Email: info@costplus.ca 		Enrollment Form
Enrollment Type *
Company: * Year End:
Company Address: *
City: *    
Province: * Postal Code: *
Phone: * Fax:
Contact Person: * Accountant:
Email Address: Referred By:
Employee Name: * Date of Birth:
Home Address: City:
Province: Postal Code:
Phone Home: Phone Cell:
Listing of Dependents: Please list all dependents that will be covered under this plan.
Name of Dependent(s)
Relationship
Date of Birth
Dependents of an Eligible Employee are defined as follows:
a) A spouse who is either legally married to employee or who is living with the employee and is publicly represented as the Employee's spouse; OR
b) Any member of the employee's household with whom the employee is connected by blood relationship, marriage or adoption; OR
c) Children over age 18 who are attending school
I wish to participate in the Private Health Service Plan provided by Cost Efficient Benefit Plan.
Date: mmm dd, yyyy Employee Name: *
Employer Approval:      
Eligibility Effective Date: mmm dd, yyyy Authorized Employer Name: *
I confirm that the above information is correct, and I have read
and accept the terms of the attached agreement. (Check box to accept terms) *
One Time Enrollment Fee: $100.00
Employee Enrollment Fee: No charge.
             
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Agreement Terms
  • Eligible under the Tax Regulations:

    Under current CRA tax regulations, incorporated businesses and eligible sole proprietors can use the services of a third party administrator to "Cost Plus" eligible medical expenses as defined in The Income Tax Act.

  • TERMS
  • 1. Coverage

    The plan covers, for the people listed on the enrollment form, all hospital, medical and dental expenses that qualify as such expenses under the Income Tax Act of Canada (ITA) and are not prohibited by law.

  • 2. Claim Submission, Approval and Payment

    The Policyholder shall submit receipts and payment for all claims listed plus the administration fee and applicable tax. The Administrator (Cost Efficient Benefit Plan), on receipt of a claim from the employee of the Policyholder, shall determine whether the claim is for an expense covered by the plan. The Administrator shall issue payment for the eligible claim directly to the individual listed on the enrollment form and shall provide notification of such payment to Policyholder if they are not the same.

  • 3. Consent to Communicate by E-Mail

    The Policyholder, by providing the email address requested above, hereby gives consent under Canada's anti-spam legislation (CASL) to Cost Efficient Benefit Plan to send information relevant to our business relationship, including but not limited to reminders, announcements and clarification of claims and other information about our services. You have the ability to withdraw your consent at any time.

  • 4. General

    The laws in force in Alberta govern this agreement. If any provision of this agreement is changed by the Federal or Provincial Government, this will affect the agreement of this form.
Page 2 of 2Please provide a void cheque for banking information to set up electronic payment of reimbursement to your personal account.