Home     |      Application Form     |      Enrollment Form     |      Login

Enrollment Form

Company Name:
*
Employee First Name:
*
Employee Last Name:
*
ID # or SIN #:
*
Login Name:
*
Password:
*
Confirm Password:
*
Employee Home Address:
*
City:
*
Province:
*
Postal Code:
*
E-mail:
*
Date of Birth:
(DD/MM/YYYY) *
Gender:
  Male    Female *
Coverage
   Single Couple Family *
Effective Date of Benefits:
(DD/MM/YYYY) *
Maximum Yearly Benefit Amount:
* (Without dollar sign and comma separator, e.g. 12345.67)
Reimbursement Percentage:
  100% 80% 50% Other *
if other, please enter amount:
%

Dependant First Name Dependant Last Name Relationship Male Female Date of Birth (DD/MM/YYYY)

Add out-of-province / catastrophic health (OOPCAT) coverage?    Y   N
OOP Coverage - $0 deductible / person
CAT Coverage - $1500 deductible / person

Monthly     

    
Copyright © 2023 Winflex Health Solutions Inc. Ver. 1.0.2301.89beab9