Cost Efficient Benefit Plan Cost Efficient Benefit Plan
(Div. of Paloma Ventures Ltd.)
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
London, ON Tel: 519-637-2200 Toll Free: 1-866-965-2201
Website: www.costplus.ca 		Enrollment Form
*
Company *
(policyholder):
Co. Year End: 
Company Address: *
City: * Province: * Postal Code : * Phone: * Fax:
Contact Person:
Accountant: 
Email Address:
Referred By: 
Employee Name (please print) * Home Address Date of Birth
Phone Home:
mm/dd/yy
Phone Cell:
City Prov Postal Code
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:   mm/dd/yyyy
Employee (type name):
Employer Approval
Authorized Employer (type name): *
Eligibility Effective Date:   mm/dd/yyyy
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 $150.00 + Tax
Employee Enrollment Fee $50.00 + Tax
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Agreement Terms
  • How is this Plan Eligible under the Tax Regulations?

    Under tax regulations, incorporated businesses and eligible sole proprietors can use the services of a third party administrator to “Cost Plus” eligible medical and dental expenses.

  • 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 Approval and Submission

    The administrator, on receipt of a claim from the employee of the policyholder, shall determine whether the claim is for an expense covered by the plan.

  • 3. Claims and Fee Payment

    Upon receipt of an eligible claim, the administrator shall issue payment for the claim by cheque directly to the individual listed on the enrollment form and shall provide notification of such payment to policyholder if they are not the same. In return, the policyholder shall issue a cheque for all claims listed plus the administration fee; in essence switching cheques.

  • 4. Reporting

    If requested, the Administrator shall provide within 30 days a report, effective as at the policyholder’s year-end (or the date requested) summarizing the claims received and paid that year.

  • 5. 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.
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