No page | PHSP | HSA | Smartin Benefits

Employee Details:

Company Name: *

Employee Full Name (First, Middle and Last Names): *

Employee's Postal Address: * Postal Address will be used to send refunds to if cheque method was selected.

City: *

Province: *

Postal Code: *

Employee Email: *

Use email to send refunds to (Interac e-transfer method)

Office Telephone: *

Alternate Telephone (Mobile or Home):

Date of Birth: *

Date of Hire: *

Annual Benefit Limit: Please provide the Employee's Annual $ Limit or Class

List of Dependents (Format: Full Name, Date of Birth, Relationship to Employee):

Authorization and Confirmation:

Note: The act of inputting your name below serves as a general electronic signature and is legally binding. Please read the applicable statements below:

Plan Administrator / Employee: I acknowledge (by typing my name below) that the information contained in this application is accurate and true to my knowledge.
Plan Administrator: I have the permission of the Employee to share the information and that the Employee was informed and is eligible to participate in the Smartin Benefits Plan.
Employee: I confirm participation and eligibility to participate in the Smartin Benefits Plan.

Authorizing Signature: *

Authorize Date: *

Last Step:

Once you completed all the required fields, click on the Enroll Employee button:

We will review and capture the information into our system.
We will update the Company's Plan Administrator with a new Plan Member Number.

Smartin Benefits Plan Owner Enrolment Form

Employee Details:

Authorization and Confirmation:

Last Step: