Insurance Forms – Life Plus Insurance

Policy Change Forms

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Cancellation Forms

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Banking Change Forms

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Beneficiary Change Forms

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Dental Plans

Dental Plan #1

:-Deductible-: {Nil}

:-Basic Services-: {80%}

:-Maximum Benefit-: {$750 per calendar year}

:-Recall Exams-: {9 months}

:-Fee Guide-: {Current}

Dental Plan #2

:-Deductible-: {Nil}

:-Basic Services-: {90%}

:-Maximum Benefit-: {$1000 per calendar year}

:-Recall Exams-: {9 months}

:-Fee Guide-: {Current}

Dental Plan #3

:-Deductible-: {Nil}

:-Basic Services-: {100%}

:-Maximum Benefit-: {$1500 per calendar year}

:-Recall Exams-: {9 months}

:-Fee Guide-: {Current}

Health Plans

Health Plan #1

:-Deductible-: {Nil}

:-EHS Co-insurance-: {80%}

:-Prescript. Drug Plan-: {Direct Pay}

:-Prescript. Drugs Deductible-: {None}

:-Prescript. Drugs Co-Insurance-: {80%}

:-Prescript. Drug Maximum-: {$2,500}

:-Hospital Accommodation-: {Semi-private room}

:-Travel Benefits: Included-: {100%, 60 days}

:-Paramedical Services-: {$500 combined}

:-Private Duty Nursing Services-: {$10,000 per calendar year}

:-Hearing Aids (Batteries Included)-: {$500 every 5 years}

Health Plan #2

:-Deductible-: {Nil}

:-EHS Co-insurance-: {90%}

:-Prescript. Drug Plan-: {Direct Pay}

:-Prescript. Drugs Deductible-: {Dispensing Fee}

:-Prescript. Drugs Co-Insurance-: {90%}

:-Prescript. Drug Maximum-: {$5,000}

:-Hospital Accommodation-: {Semi-private room}

:-Travel Benefits: Included-: {100%, 60 days}

:-Paramedical Services-: {$750 combined}

:-Private Duty Nursing Services-: {$10,000 per calendar year}

:-Hearing Aids (Batteries Included)-: {$500 every 5 years}

Health Plan #3

:-Deductible-: {Nil}

:-EHS Co-insurance-: {100%}

:-Prescript. Drug Plan-: {Direct Pay}

:-Prescript. Drugs Deductible-: {None}

:-Prescript. Drugs Co-Insurance-: {100%}

:-Prescript. Drug Maximum-: {$10,000}

:-Hospital Accommodation-: {Semi-private room}

:-Travel Benefits: Included-: {100%, 60 days}

:-Paramedical Services-: {$1000 combined}

:-Private Duty Nursing Services-: {$10,000 per calendar year}

:-Hearing Aids (Batteries Included)-: {$500 every 5 years}