EMPLOYEE ENROLMENT FORM

FOR HEALTH & DENTAL ENROLMENT, POLICY CHANGES & TERMINATION

for determination of employee credits coverage
Your e-mail is required to receive your account balance and other important information

I agree that my email may be used to receive information regarding my benefits plan. This information will not be reused and will be kept confidential


If yes, please submit claims to your spouse's insurance plan first



if yes, then consider extra dental credits at your-benefits.ca



I have reviewed the above information and sign off on the accuracy of adjustment, additions or removal of Health & Dental Benefits