Flexible Benefits Employee Registration Form

Please enter your name
(firstname lastname)

Your Name
Your social insurance number:    

Social Insurance Number
Enter your age as of January 1, 2001:

Your Age
Please indicate if you are a smoker or if you have smoked in the last year:

Smoking
Please select your province of residence:

Province
Please enter the effective date of your coverage:

                    

MM           DD         YYYY

Date of Coverage
Do you have a spouse?

Spouse
Please indicate if you have any dependents:

Dependents

Beneficiary Information

Beneficiary name

Percent

Relationship

Flex Credit Calculation

Please enter your annual salary: 
Note: do not enter  the "$" symbol

Salary

Click to calculate your flex credit:  

Select you preferred benefit levels for the proposed FLEX program in the following sections. All costs are in pre-tax dollars and are shown in the right hand of each option. Your remaining flex credits are shown in the lower center of each section.

Health Insurance
1. Basic Medical Plan

2. Opt.1 + $100.00 elective
3. Opt.1 + $500.00 elective
4. Opt.1 + $1000.00 elective
5. Opt.1 + $1500.00 elective
6. Opt.1 + $2000.00 elective
7. Decline

Credits left:

Dental Insurance
1. Basic preventive services
2. Opt.1 + $250.00 elective
3. Opt.1 + $750.00 elective
4. Opt.1 + $1,000.00 elective
5. Opt.1 + $1,500.00 elective
6. Opt.1 + $4,000.00 elective
7. Decline
Credits left:

LTD
1.

70% of salary, 3% indexing.

Credits left:

Life Insurance
1. 1 times your annual salary
2. 2 times your annual salary
3. 3 times your annual salary
4. 4 times your annual salary
Credits left: