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Application and Agreement

For the Employer

Advisor Information

Employer Information

ⓘ Name of the individual who will be responsible for plan administration and monthly invoices. Individual must have company signing authority.

ⓘ Enter Work/Professional Email Address Only

ⓘ Employer’s legal business name, either name or incorporation number

ⓘ “Doing business as” name, if different than the employer’s legal name

Agreement Effective

Agreement is effective on the first day of the selected month following the Employer’s date of Signature and on each subsequent Anniversary Renewal

ⓘ Select the specific options below, to define the benefits for a Class, such as “Executives” or “Employees”


ⓘ Note: After no more than 24 months of employment, including credit for months in another eligible class.

Definition of Eligible Dependents

Dependents:

Spouse or Common Law Spouse of the Employee, and children of the Employee, Spouse or Common-Law Spouse

Other Dependents

Grandchildren of a participant, Spouse,/Common-Law Spouse. Parents, Grandparents, Brothers, Sisters, Uncles, Aunts, and Nieces and Nephews; residing in Canada and related by blood, marriage or adoption to the Employee or Spouse. Residency Requirement doesn't apply to the children of the Employee or Employees Spouse.
Criteria for the relation being deemed adependent include: the relation is wholly dependent for support; and/or under the age of 18; or dependent on the individual by reason of a mental or physical infirmity.

Eligibility as a dependent is a matter of fact; if uncertain seek professional assistance and refer to Income Tax Folio S1-F4-C1

Claims

First Plan Year
Reimbursement can be selected at: 80% or 100% at a calendar year benefit of $1,000 Single, $2,500 Family or more

ⓘ Note: first year, and subsequent years, maximums are available to all eligible participants, regardless of effective or termination date.


Subsequent Plan Years
Reimbursement can be selected at: 80% or 100% at a calendar year benefit of $1,000 Single, $2,500 Family or more

Benefits

Subject to the Calendar Year Maximums, all benefits allowed in CRA Income Tax Folio S1F1C1 the “Medical Expense Tax Credit” including, but not limited to, those shown in the benefit booklets.

ⓘ Select the specific options below, to define the benefits for a Class, such as “Executives” or “Employees”


ⓘ Note: After no more than 24 months of employment, including credit for months in another eligible class.

Definition of Eligible Dependents

Dependents:

Spouse or Common Law Spouse of the Employee, and children of the Employee, Spouse or Common-Law Spouse

Other Dependents

Grandchildren of a participant, Spouse,/Common-Law Spouse. Parents, Grandparents, Brothers, Sisters, Uncles, Aunts, and Nieces and Nephews; residing in Canada and related by blood, marriage or adoption to the Employee or Spouse. Residency Requirement doesn't apply to the children of the Employee or Employees Spouse.
Criteria for the relation being deemed adependent include: the relation is wholly dependent for support; and/or under the age of 18; or dependent on the individual by reason of a mental or physical infirmity.

Eligibility as a dependent is a matter of fact; if uncertain seek professional assistance and refer to Income Tax Folio S1-F4-C1

Claims

First Plan Year
Reimbursement can be selected at: 80% or 100% at a calendar year benefit of $1,000 Single, $2,500 Family or more

ⓘ Note: first year, and subsequent years, maximums are available to all eligible participants, regardless of effective or termination date.


Subsequent Plan Years
Reimbursement can be selected at: 80% or 100% at a calendar year benefit of $1,000 Single, $2,500 Family or more

Benefits

Subject to the Calendar Year Maximums, all benefits allowed in CRA Income Tax Folio S1F1C1 the “Medical Expense Tax Credit” including, but not limited to, those shown in the benefit booklets.

ⓘ Select the specific options below, to define the benefits for a Class, such as “Executives” or “Employees”


ⓘ Note: After no more than 24 months of employment, including credit for months in another eligible class.

Definition of Eligible Dependents

Dependents:

Spouse or Common Law Spouse of the Employee, and children of the Employee, Spouse or Common-Law Spouse

Other Dependents

Grandchildren of a participant, Spouse,/Common-Law Spouse. Parents, Grandparents, Brothers, Sisters, Uncles, Aunts, and Nieces and Nephews; residing in Canada and related by blood, marriage or adoption to the Employee or Spouse. Residency Requirement doesn't apply to the children of the Employee or Employees Spouse.
Criteria for the relation being deemed adependent include: the relation is wholly dependent for support; and/or under the age of 18; or dependent on the individual by reason of a mental or physical infirmity.

Eligibility as a dependent is a matter of fact; if uncertain seek professional assistance and refer to Income Tax Folio S1-F4-C1

Claims

First Plan Year
Reimbursement can be selected at: 80% or 100% at a calendar year benefit of $1,000 Single, $2,500 Family or more

ⓘ Note: first year, and subsequent years, maximums are available to all eligible participants, regardless of effective or termination date.


Subsequent Plan Years
Reimbursement can be selected at: 80% or 100% at a calendar year benefit of $1,000 Single, $2,500 Family or more

Benefits

Subject to the Calendar Year Maximums, all benefits allowed in CRA Income Tax Folio S1F1C1 the “Medical Expense Tax Credit” including, but not limited to, those shown in the benefit booklets.

Administration

Administration: 10% of claims submitted and paid.

Ontario Taxes

Ontario 8% RST: is charged on all Claims submitted and paid.
Ontario 13% HST: is charged on the Assureflex Administration Fees.
Ontario 2% Premium Tax: charged on Claims plus Administration.

NSF Cheque Fees

Any NSF cheque received, will result in Claims being placed on hold, and the Plan being suspended until full payment (including NSF and all other fees) are received. fees $50.00 in addition to any other fees.

Collection Fees

Any Invoices remaining unpaid 30 days after invoice date (15 days after due date), will result in Collection Notice and the Plan suspended until full payment received. fees $100.00 in addition to any other fees.

Legal Notice Fees

Any Invoices remaining unpaid 45 days after invoice date (30 days after due date), will result in Legal Notice and the Plan being subject to termination after payment. fees $250.00 in addition to any other fees.

Processing

Claims Forms, regardless of the number of expense receipts included (whether for payment by Cheque or by Direct Deposit), are subject to a Claims Processing Fee. fees $3.75 in addition to any other fees.

Processing

Claims Forms under $100 are subject to an added processing fee. Claim expenses, even if over balance (eligible in next year using Explanation of Benefits provided). fees $5.00 in addition to any other fees.

Reprocessing

Cheques returned due to incorrect mailing address, will result in such cheque being considered as void, and a replacement cheque being processed with correct address. fees $25.00 in addition to any other fees.

Stop-payments

Stop-payment, or change from Direct Deposit to cheque, result in the payment being considered as void, and a formal bank stop-payment being processed for transaction. fees $25.00 in addition to any other fees.

Incorporated Employers

HSAflex is available to bona fide employees of corporations, earning a salary, starting with as few as one employee. Executives (who are also Shareholders), maximum “must be reasonable”, ie: no more than 10% of active earnings (T4).

Note: This is a Canada Revenue Agency requirement.

Note: Do not use “Shareholders” as an eligible benefit Class.

Non-Incorporated Employers

HSAflex is available to bona fide employees of non-incorporated businesses, who are “arms-length” employees. An actively employed owner can participate, if the benefits arranged are the same as those of the “arms-length” employees.

Note: This is a Canada Revenue Agency requirement.

Note: Do not use “Owners” as an eligible benefit Class

Administration Fees

Employer hereby agrees to provide Assureflex with funds sufficient to fully indemnify eligible Expenses incurred by the eligible Employees, or their eligible Dependents, and the applicable Administration Fees as a percent of the Claims Paid, plus all applicable Taxes. Employer also guarantees to fully indemnify Assureflex for any and all time and expenses incurred in the collection of any funds which are in arrears or default by the Employer.

Claims Indemnification

Assureflex hereby agrees to provide funds sufficient to discharge actual eligible Expenses incurred by the enrolled Employees, or eligible Dependents, by payment of such applicable funds directly to the Health Care Provider or Dental Care Practitioner, or reimbursement to the enrolled Employee if such eligible Expenses have already been paid by the Employee, and an original of Receipt of Payment is provided to Assureflex as evidence of payment.

Prepayment of Claims

On receipt of any Claims Form in excess of $2,500.00, Assureflex will review the Claim for eligibility and calendar year maximums, and may invoice Employer for payment of the eligible Claim, Administration Fees and applicable Taxes. On receipt of payment from the Employer, Assureflex will process the Claims payment to the Employee or the Provider. Change to prepayment is applied to Employers if any Invoice exceeds 30 days for payment.

Enrollment Requirement

Eligible Employees shall be advised of benefits available to them and eligible Dependents, and all eligible Employees shall be indemnified for all eligible Health and/or Dental Care expenses incurred by them, or incurred by their eligible Dependents, in accordance with the Assureflex eligible provided expenses, until Notice is given by Employer to Assureflex that the enrollment of the specified Employee is terminated as of the date given in such notice.

Carry Forward Provisions

Any unused portions of the calendar year Benefit Maximums are not carried forward to the following Calendar Year. Unused portions of calendar year Benefit Maximums become unavailable for Claims processed after December 31st . Claims may be carried forward to the following calendar year, but can be no older than twelve months on date submitted, to conform to the Income Tax Act and the Canada Revenue Agency Regulations.

Legislative Requirements

It is the obligation of the Employer to ensure that Claims for eligible Employees and eligible Dependents and applicable Assureflex Administration and Consulting Fees, and Federal and Provincial Taxes are submitted to Assureflex, and eligibility of Employees and Claims submitted conform to the provisions of the Income Tax Act and Regulations of the Canada Revenue Agency shown in Tax Folio S1F1C1 or subsequent revisions.

Amendment or Termination

The Agreement may be amended or terminated by either party on thirty days written Notice, subject to completion of any and all transactions started prior to the change. If there are no eligible Claims processed within any consecutive 12 month period, then Assureflex has the option to terminate this Agreement without further notice, subject to any and all financial obligations of the Employer remaining in full force and effect.

Payment of Monthly Invoices

Invoices are provided at the 1 st. or the 15th. of each month, for payment within the first 10 days of invoice. If full payment has not been received within 15 days of invoice, then Employee Claims are held until full payment is received. If full payment is not received within 30 days of invoice, the plan is suspended and collection procedures are started. Assureflex will be a Secured Creditor of the Employer, and its Officers and Directors.