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Personalized Health Care Plans For Canadian Small Business
~No Monthly Premiums~

Employee Registration Form

Company Name:
Employee Name:
 
Employee Address
Street:
City:      
Province: Postal Code:
Home Phone: Date of Birth:    
 
Employee Classification
Executive Management Full Time Part Time Other
 
  Name of Dependant Relationship to Employee Date of Birth
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Dependents of an Eligible Employee are defined as:

  1. A Spouse — who is either a) legally married to the Employee; or b) a person who is living with
    the employee and who is publicly represented as the Employee’s spouse, significant other, life
    partner or mate.
  2. Any member of the employee's household to whom the employee is connected by blood
    relationship, marriage or adoption; who is 18 years of age or younger, or is up to 25 years of age
    and attending post-secondary schooling full-time.

I wish to participate in the Heartland Medical Health Care Plan and confirm that the above information is correct.