navancorp Plan Member Enrollment Form

Company/Corporation Name

Employees (Format: Name, Home Address, City, Province, Postal Code, Email Address, Date of Birth, Benefit Class)

Email

Authorization and Confirmation The act of inputting your name below serves as a general electronic signature and is legally binding. As the Plan Administrator: I acknowledge (by typing my name below) that the information contained in this application is accurate and true to my knowledge. I have the permission of the Employee to share the information and that the Employee was informed and is eligible to participate in the Navancorp Benefits PHSP.

Authorizing Date

Plan Member Enrollment Form

Navancorp PHSP Member Enrollment Form

Private Health Services Plan (PHSP)