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Contract

For our Private Health Services Cost Plus Plan contract form submission, please use the download link on this page and submit the form to:

Clews Benefits Management
248 Lindsay Ave
Red Deer, AB
T4R 3P3

Clews Benefits Management

PRIVATE HEALTH SERVICES COST PLUS PLAN

PLAN SUMMARY

Plan Administrator Clews Benefits Management 248 Lindsay Ave Red Deer, AB T4R 3P3

PHONE: 1-877-779-4237 FAX: 1-866-517-0434

Insurer & Address

Insured: The employees of the Policyholder and their eligible dependents as determined by the Policyholder

Administrator's Fee: _10%_ OF ALL CLAIMS SUBMITTED (Taxes on Admin fee Extra)

Term: The agreement will commence on the effective date and continue for a one-year period. This agreement shall be automatically renewed for successive one-year periods thereafter unless either party sends to the other a written notice of non-renewal at least 30 days prior to the date of commencement of each renewal term.

Plan Start Date: The Administrator and the Policyholder agree to establish and administer the Private Health Services Plan ("Plan") on the terms specified below, effective as of the 1st day of

Per

Per

TERMS

1. COVERAGE: The Plan covers all hospital, medical and dental expenses of the Insured ("Claims") that: qualify as such expenses under the Income Tax Act of Canada ("ITA"); are not prohibited by law; and are approved and submitted by the Policyholder.

2. POLICYHOLDER CONTRIBUTIONS: The Policyholder shall submit full payment with claims. Payment submitted is to include Administration fees and all applicable taxes. This method of payment is effective immediately and remains as long at the Plan is in force. The Administrator, at its option and with reasonable notice, may require an additional payment(s) if, in its reasonable assessment, such a payment(s) is necessary to fund its known or projected obligations including, without limitation, the payment Claims and the Fee. Any additional payments by the Policyholder are herein sometimes collectively called the "Contributions".

3. CLAIM APPROVAL AND SUBMISSION: The Policyholder, on receipt of a claim from its employee, shall determine whether the claim is from an Insured and is for an expense covered by the Plan. The Claim, as approved by the Policyholder, shall be submitted to the Administrator. All Claims submitted to the Administrator shall be deemed to have been approved by the Policyholder and the Administrator shall be under no further obligation to confirm such status.

4. CLAIMS AND FEE PAYMENT: Upon receipt of the Claim, the Administrator shall issue payment for the Claim by cheque directly to the individual Insured and shall provide notification of such payment to the Policyholder. The Administrator has collected in advance from the Policyholder at the time the cheque for the Claim is issued.

5. INSURER INDEMNITY: Should the Policyholder request the Administrator to pay a Claim for which there are not sufficient Contributions on deposit to the Policyholder's credit and should the Administrator agree, at its sole option, to make such payment, the Policyholder shall: be liable for; and indemnify and save harmless the Administrator from all manners of action, causes of action, damages or expenses whatsoever which may be brought or made against the Administrator as a result of making such payment and to the Administrator for such payment and the Fee.

6. TERMINATION PRIOR TO THE TERM DATE: The Administrator or the Policyholder may terminate this Agreement on 30 calendar days' written notice to the other at the address indicated.

7. TAX TREATMENT: The characterization of the Contributions and the Claims paid under the ITA is a matter to be assessed solely by the Policyholder and the Administrator .

8. GENERAL: Time is important. This Agreement is governed by the laws in force in Alberta. If any provision of this Agreement is found by a court of competent jurisdiction to be unenforceable then such provision shall be severed and the remaining terms and covenants shall be unaffected and enforced to the greatest extent permitted by law. No amendment of the Agreement shall be valid unless in writing and signed by the Policyholder and the Administrator. Words importing the singular number include the plural and vice versa as required by the context. The Summary forms part of this Agreement.

Effective as of

Broker
___________________________

Policyholder
Per:
Name :

Enrollment

Please use the link in this section to download a PDF version of the Enrollment Form.

Please note that the enrollmentĀ form is only available on computer browsers and will not be made available on small tablets and mobile devices.

Clews Benefits Management

Enrollment Card for Employee Benefits

 

Is this your first time enrolling on this plan?  Yes No

Last Name

First Name Name

Date of Birth

Address:

Phone Number:

Fax Number:

 

Are you choosing: (Please check)
 Single Coverage Family Coverage Waive/No Coverage


If applicable, please enter all dependent information. If the dependent is not a resident of the same province as you (the employee), please note their province

Name

Date of Birth

Relationship

Are they attending school full time

 

 

 

 

 

Effective Date of Enrollment:

_____________________________________________
Employee Signature
_________________________________
Date
 

Claims Form

Use the link in this section to download the Cost Plus Benefit Claim Statement form.

Please note that the claims form is only available on computer browsers and will not be made available on small tablets and mobile devices.