Company Legal Name
* |
Company Operating Name (if different)
|
Street Address
* |
City
* |
Province
* |
Postal Code (i.e. T2B 3H4)
* |
Mailing Address (if different)
|
City
|
Province
|
Postal Code (i.e. T2B 3H4)
|
Phone Number (i.e. 403 2445555)
* |
Fax Number (i.e. 403 2445555)
|
Contact Person Name
* |
Contact Business Email
* |
Contact Position
* |
Contact Cell Number (i.e. 403 2445555)
|
Preferred Method of Contact
* |
Business Type
*
|
Fiscal Start of Year
* |
Start Date of Program
*
|
Company Website
|
Total Employees (NOTE: Minimum 1 - i.e. Business
Owner. If 15 or more, please call us)
* [More
information] |
| |
How do you wish to fund the Employee Health Plan?
*
|
| |
What do you want to do with the unused portion of your employees' benefits at the end of the year?
* [More
information] |
| |
Eligible Expenditures - Indicate the type of eligible expenditures you want your plan to cover.
* [More
information] |
| |
When are employees eligible to participate in this plan?
*
If OTHER, Specify number of months following the hire date: months |
| |
When does the employee become terminated from the plan?
*
If OTHER, Specify number of days following termination, eg., 30, 60, etc.: days |
| |
If the first year of the plan is less than a full fiscal year, what should the benefit level be?
*
|
| |
If a new employee's first year of eligibility is less than a full fiscal year, what should the benefit level be?
*
|
| |
When do employee claims have to be received by MediDirect® to be included in the Company's fiscal year?
*
If OTHER, Specify number of days after the end of the Company's fiscal year: days
|
| |
|
Employee Information/Benefits Levels (Required Information)
Please indicate the annual fixed maximum benefit level you wish for each classification
of employee. If you want a different benefit level for employees without dependents,
please indicate the amount in the appropriate column. Otherwise, the same benefit level
will apply to all employees in each classification whether they have dependents or not.
|
Employee Classification |
Annual Reimbursement Level |
| Description |
With Dependents |
Without Dependents |
| Executive |
With
|
Without
|
| Senior Management |
With
|
Without
|
| Full-time Employees |
With
|
Without
|
| Part-time Employees |
With
|
Without
|
| Hourly Staff |
With
|
Without
|
| Commissioned Staff |
With
|
Without
|
| Other |
With
|
Without
|
| Additional Information
|
Referral Information *
Please tell us how you learned about the MediDirect® Plan.
Check all that apply.
|
Privacy Statement
At MediDirect® Inc., the privacy of clients, employees and their
records is our priority. Confidential information is maintained in
files regarding your contract with us, as well as personal and medical
information. Our files are kept for the purpose of providing you with
health and dental benefit plan coverage and other products or services
that will help you meet your health and wellness objectives. This personal
information will not be sold, leased, rented or given to any third
party, without prior written consent. Access to personal information
is restricted to only those employees of MediDirect® Inc. who are
responsible for administration, the Privacy Officer of MediDirect® Inc.,
or any other person(s) whom you authorize. Our
full web privacy commitment is available here. |
|
