Corporate / Individual Enrollment – Health & Welfare trust
(Please complete all fields.) |
| Please choose one option:* |
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| # of Employees (if applicable): |
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| Corporation Name (if applicable): |
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| Address:* |
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| City:* |
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| Province:* |
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| Postal Code:* |
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| Key Contact Information:
(this person will be the main contact person for your Private Health Service Plan account) |
| Salutation:* |
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| First Name:* |
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| Last Name: * |
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| Telephone:* |
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| Fax: |
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| Email:* |
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| Enrollment Details: |
| Effective Date (mm/dd/yy):* |
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| Corporate Year End Date (if incorporated) (mm/dd/yy): |
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| How would you like to receive your Registration documents?* |
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| How would you like to receive your Invoices?* |
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| How will payments be made to the trustee?* |
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| Would you like to use the Internet to manage your Account?* |
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| In Province / Out of Province Medical option:* |
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