National HealthClaim - General HSA Enrollment

STEP 1: Company Information



Your legal business name




Format Example: T2V 1X4

Example format: 403-123-4567

Use "none" if no broker involved

​For help with this form, please phone​ ​toll-free​ ​1 866 342-5908​ ​or​ ​visit​ ​​our support center website.

STEP 2: Healthcare Spending Account Setup

Select your Plan Details
  1. Choose job classification(s) for the employees of your company.  You will assign Classifications to employees later in this application form.  It is required that each employee within a classification be extended the same annual limits.
  2. Please make sure the descriptions are accurate. Example text is shown below.
  3. Enter the annual limit amounts. The amounts shown are default - any amount can be entered.
Job Classification A



Any amount can be entered.

Any amount can be entered.



Job Classification B



Any amount can be entered.

Any amount can be entered.


Job Classification B



Any amount can be entered.

Any amount can be entered.


Job Classification C



Any amount can be entered.

Any amount can be entered.



mm/dd/yyyy
When the plan is to start. The plan can be back-dated up to one year (will apply to all employees). 


The benefit year based on any 12 month period.
The 12 month cycle that claims are made against. You can align it to your fiscal year or keep it to a calendar year. 



Credit Carry: Unused credits from one benefit year can transfer to the next year after the runoff period has ended.
Expense Carry: Expenses (receipts) from one benefit year can be claimed in the next year, after the runoff period has ended.
No Carry: Credits must be used within each benefit year only.

60 days is typical
Number of days from start of new benefit year during 
which claims can be made against the previous year. 
Typical is 60 days to allow adequate time. 

Child dependents attending full-time post secondary school remain eligible until, and including, this age. Child dependents remain eligible until, and including, this age.

STEP 3: Company Contacts


Enter the details for the company plan administrator here.
Plan Administrator





Enter in mm/dd/yyyy format

Enter in mm/dd/yyyy format

Example format: 403-123-4567


Dependant


Enter in mm/dd/yyyy format


Add dependant

Employee(s)




Enter in mm/dd/yyyy format

Enter in mm/dd/yyyy format


Dependant


Enter in mm/dd/yyyy format


Add dependant
Add another employee

STEP 4: Plan Authorization

By checking the box above this the company agrees to provide a HealthCare Spending Account for its employees and will pay for all account funding and administration fees as required. This forms a contract of Insurance (copy available online for Company Administrator).

If you checked "1-8 employees" in step 1, your account will not be activated until we receive $300 +GST enrollment fee.