Private Health Service Plan Enrollment Form Part A. Plan Sponsor Incorporated Business?
Business Name:
YES
Street Address: Province:
City:
ON
Postal Code:
Authorized Person:
Phone:
Email Address:
Fax:
Part B. Terms and Conditions The Heritage Benefits Administration Inc. shall provide the following services to the Plan Sponsor: 1. Heritage Benefits Administration Inc. (The Heritage) establishes and manages a Private Health Services Plan (PHSP) plan for the Plan Sponsor in accordance with Subsection 248(1) of the Income Tax Act, for the Plan Sponsor. A summary of PHSP is specified in The Heritage PHSP Plan Design (Part C) of this form. 2. The Heritage establishes accounts for the Plan Sponsor and all Covered Employees, as listed in Part D of this form and authorized by the Plan Sponsor. The Heritage reimburses the Covered Employees for all Eligible Expenses under the PHSP plan.The Plan Sponsor authorizes The Heritage to apply payments from the Plan Sponsor's PHSP account, in settlement of eligible benefits, payable to employees, and settlement of administration fees due to The Heritage. 3. The Heritage reviews all claims submitted by Plan Sponsor and its employees for eligibility of expenses. Eligible Expenses are those defined in Subsection 118.2(2) of the Income Tax Act. A direct link to the legislation and associated interpretive documentation is available on the The Heritage Benefits Administration website (www.HeritageBenefitsAdmin.com). The Heritage reserves the right at its sole discretion to identify expenses as ineligible, and not process the claim. In this case, all original documents and payments will be returned to claimant. 4. The Heritage insures the claim has been properly completed, has a service date within the qualified range, is authorized and funded. Upon completion of the claim adjudication, The Heritage, within 7 business days, will issue a reimbursement payment, for the total cost of the Eligible Expenses to the claimant. Unadjusted claims will not be paid and all original documents will be returned to claimant. 5. The Heritage provides timely reporting, including an Annual Client Statement for tax purposes, as required and appropriate for the Plan Sponsor, to reconcile all transactions in the accounts of the Plan Sponsor and the Covered Employees for the fiscal year. 6. Privacy Statement. The Heritage will follow the guidelines and procedure manuals set forth by the respective federal government privacy legislation, the Personal Information Protection and Electronic Documents Act, and the Provincial Personal Health Information protection Acts. 7. The Heritage will hold all funds received from the Employer on the account that bears no interest to the Plan Sponsor.
Accountabilities of the Plan Sponsor : 1. The Plan Sponsor will ensure the plan remains funded as outlined in the attached Fee Schedule, in a manner necessary to meet its obligations to its employees and The Heritage. In the event the Plan Sponsor fails to fund the plan as required, The Heritage is under no obligation to, and will not payout claims submitted by the employees. 2. The Plan Sponsor provides and maintains an up-to-date list of all eligible employees and their coverage limits. The Plan Sponsor shall endorse the accuracy of the information provided and eligibility of employees.The Plan Sponsor shall notify The Heritage immediately about changes, affecting the eligibility of any employees and/or dependents, and changes in coverage limits, in a manner that is satisfactory to The Heritage. 3. The Plan Sponsor shall be responsible for paying appropriate, applicable taxes, even if taxes were not collected by The Heritage. The Heritage does not provide tax advice. Consult your tax adviser for additional tax information .The Heritage is not liable, in any way, for any incurred financial losses, caused by either inaccurate or outdated information, supplied by the Plan Sponsor
The Heritage Benefits Administration Inc., Suite 306, 15 Wertheim Crt., Richmond, ON
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Private Health Service Plan Enrollment Form Fee Schedule: Plan Sponsor Fee Schedule Payable to Heritage Financial Services Ltd. 1. Enrollment Fee - Seventy Five dollars ($75.00) is to be paid with this application. 2. Administration Fees - calculated as 5% of benefits paid, plus H.S.T. on the administration fee only. In addition, Premium tax and Federal and Provincial sales taxes may be levied on reimbursement and fees when applicable. 3. Thirty dollars ($30.00) will be charged for all NSF cheques. 4. Unused benefits at fiscal year-end will be rolled over to the next year. This agreement can be terminated immediately by either party upon delivery of written notice to the offices of the other party. Termination of this agreement constitutes termination of The Heritage PHSP. In the event this agreement is terminated, The Heritage shall have no obligations, under the PHSP, beyond paying claims incurred prior to the date of termination and funded already by Plan Sponsor, including fees and applicable taxes due to The Heritage. All money left in deposit in the Plan Sponsor`s account shall be returned to the Plan Sponsor upon termination of the PHSP.
Part C. PHSP Plan Design Number of Eligible Employees:
1
Funding Options:
Pay as you go
31-12
Company Fiscal Year End:
Shareholders are eligible for the PSHP as an employee, actively involved in the business. Please note: for Ontario companies, premiums for group plan are subject to 8% PST tax. For more information, please contact your tax adviser. Effective Date. The date after which coverage will begin under the plan. This date should be within a 12- month period, ending in the current fiscal year. Each Covered Employee could have a different Effective Date, as specified in Part D.
01-01-2014
Year Anniversary Date for the Plan (not applicable for Pay-as-you-go plans). By default will be the Calendar Year, unless otherwise specified. This date does not affect delivery of your tax reports. If, for some reason, you need to change it, specify it here:
31-12
For incorporated companies, each Covered Employee could be offered benefits under Classes, based on position within the firm. Each Class may have a different benefits limit and percentage of employee contribution. The Plan Sponsor may not limit participation in The Heritage Health PHSP, based solely on position as a shareholder. Class Name:
Class Description:
Class A:
Unlimited Coverage. (Incorporated Companies only)
Benefits Maximum:
Employee Co-Payment:
Class B:
$0.00
0%
Class C:
$0.00
0%
Class D:
$0.00
0%
For Unincorporated businesses, according to CRA regulations, the owner, spouse, and related adults of the household can claim a maximum of $1,500 per year. Minor children (under 18 years of age) can claim up to $750 per year. Unrelated employees can be provided greater or lesser maximum amounts. However, this amount should not be less than assigned to the business owner and spouse.
The Heritage Benefits Administration Inc., Suite 306, 15 Wertheim Crt., Richmond, ON
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Private Health Service Plan Enrollment Form Part D. Covered Employees Coverage for the employee includes the employee, the employee's spouse, or any member of the employee's household, with whom the employee is connected by blood relationship, marriage, or adoption. To Add more employees use a separate form. Eligible Date:
Employee Name:
01-01-2014
Street Address: City: Email Address:
Province: ON Class:
A
Postal Code: Direct Deposit? If so attach VOID Cheque Eligible Date:
Employee Name:
01-01-2014
Street Address: City: Email Address:
Province: ON Class:
A
Postal Code: Direct Deposit? If so attach VOID Cheque Eligible Date:
Employee Name:
01-01-2014
Street Address: City: Email Address:
Province: ON Class:
A
Postal Code: Direct Deposit? If so attach VOID Cheque Eligible Date:
Employee Name:
01-01-2014
Street Address: City: Email Address:
Province: ON Class:
A
Postal Code: Direct Deposit? If so attach VOID Cheque
I, an authorized representative of the Plan Sponsor, hereby confirm accuracy of the information provided in this form. I agree to notify The Heritage immediately of any changes to the plan.
Plan Sponsor Authorized Signature:
Date:
Authorized Person Name: Date: The Heritage Authorized Signature:
The Heritage Benefits Administration Inc., Suite 306, 15 Wertheim Crt., Richmond, ON
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