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Enrollment Reminder

This email has been generated automatically on behalf of your employer for your immediate attention. Please reach out to your benefits administrator with any questions.

Dear (EmployeeFirstName, EmployeeLastName),

This a friendly reminder regarding your outstanding benefits Enrollment application.

Please click on the secure link in this email to access and complete your application.
‍
‍<Enrollment Form>

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Additional notes (optional)

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Enrollment form

Employer Data

Member Information

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First name

Last name

Member email address

Billing group

Letter:

View PDF

Brochure:

View PDF

Letter (optional)View PDFExclude Letter

Brochure (optional)View PDFExclude Brochure

Service Plan

Group Plan

Ineligible

Class description

Credit amount

Flex:

Group Plan

Class description

Credit amount

Ineligible

Plan Coverage Options

Group Plan

Permanent date employed

Employee number (optional)

Salary amount

Earning per

Hours work / week

Occupation

Save draft employer data

Thank you! Your submission has been received!

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Member details

Email address

jon.smith.industries@email.com

First name

ADAM

Last name

LOWRY

Gender

Male

Birth date

1986-04-14

Mailing address

123 Main Street

City

Winnipeg

Province

Manitoba

Postal code

R3V 0R3

Home phone (optional)

(204) 230-1234

Work phone (optional)

(204) 230-1234

ext. (optional)

123

Do you have a Provincial Health Number?

Yes

Spouse/Dependent(s)

Common-law/Spouse

First name

Jane

Last name

Smith

Relationship

Spouse

Birth date

1995-11-01

Gender

Female

Dependent

First name

Mark

Last name

Smith

Relationship

Child

Birth date

2020-09-09

Gender

Male

Incapacitated

Additional information

Cohabitation date

Plan coverage

Plans

Dental Service Plan

Dental

Life/Disability

Beneficiary(ies)

First name

Last name

Relationship

Percentage

None

Trustee

First name

None

Last name

None

Relationship

None

Email (optional)

None

Phone

None

Address

None

City

None

Province

None

Postal code

None

ext. (optional)

None

Optional life

None

Optional spousal life

None

Optional dependent life

None

Optional accidental death and dismemberment

None

Life and disability benefits are underwritten by Blue Cross Life Insurance Company of Canada. All amounts are subject to approval.

Coordination of benefits

Benefits provider

Canada life Ins

Benefits covered

First name

Jon

Last name

Smith

Relationship

Self

Health

Direct deposit

Direct deposit information

Transit number

12345

Institution number

123

Account number

12345

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