IBA PHSP Registration Form

Section A - General Information

Plan Owner

Name of corporation, partnership or sole proprietor

Business Address Line 1

Business Address Line 2

City/Town

Province/Territory

Postal Code

Primary Contact

Phone Number

Alternate Contact

Phone Number

Effective Date

Effective date when coverage begins under the plan

Fiscal Year End

Fiscal month when the business year ends

Benefit Anniversary

Calendar month when annual coverage renews

Is the business incorporated?

Yes No * More information is required if not incorporated

Annual Benefit Coverage Limits by Category
* If no limits are specified, the default will be 'Unlimited'

Category A

Category B

Category C

Category D

Category E

Category F

Section B - PHSP Terms (Please read carefully)

* Select PHSP Terms to toggle between showing and hiding the detail.

PHSP Terms

(1) In accordance with Subsection 248(1) of the Income Tax Act, Intendo Benefits Administration Inc. (IBA) by this registration form establishes a “cost plus” Private Health Services Plan (PHSP) with the business / employer (Plan Owner) identified in Section A. IBA indemnifies the covered employees (Plan Members) of the Plan Owner for all eligible expenses for the agreed upon administration fee to be paid by the Plan Owner upon submission of any claim on behalf of the Plan Member.

(2) The IBA PHSP applies to all eligible expenses. For this agreement eligible expenses refer to those defined in Subsection 118.2(2) of the Canada Income Tax Act. These are outlined in Canada Revenue Agency (CRA) Interpretation Bulletin IT-519R2.

(3) The IBA PHSP provides benefit coverage to all Plan Members as specified by the Plan Owner. The term Plan Member includes the employee, the employee’s spouse or any member of the employee's household with whom the employee is connected by blood relationship, marriage or adoption. There is no limitation by age.

(4) The Plan Owner will establish an effective date from which coverage is provided by the PHSP. This can be any date between the start and end dates of the current fiscal year of the business.

(5) The Plan Owner may elect to offer this benefit plan to Plan Members in varying levels of maximum benefit at its sole discretion. For this IBA PHSP the Plan Owner has established the categories of maximum benefit coverage level as specified in Section A.

(6) The Plan Owner may add or update Plan Members and their associated information via the IBA PHSP Claim form as claims are submitted. Plan Members may be removed from this IBA PHSP via an email request from the Plan Owner.

(7) IBA will adjudicate each claim submitted to ensure the following:
a. The expenses are eligible as per Section B(2).
b. The Plan Member is eligible as per Section B(3).
c. The maximum benefit coverage level and dates set by the Plan Owner are not exceeded.
d. The claim form has been properly completed and authorized, the corresponding payment is provided to cover the total amount due, and all supporting receipts are attached.

(8) Upon completion of the claim adjudication, IBA will issue a reimbursement for the cost of all eligible expenses to the Plan Member via direct bank deposit, as per the direct bank deposit detail provided.
Note: Direct bank deposit detail provided only authorizes IBA to make deposits into the account. No other form of account transaction is permitted.

(9) IBA will issue tax receipts to the Plan Owner to allow the business to claim the cost of registration, eligible expenses, administration fees and applicable taxes per transaction.

Section C - Registration Fee

The total fee due with this registration is $ CAD.

Note: This registration fee is tax exempt and there are no annual renewal fees.

Employees (Plan Members) can be added or their relevant information updated via our PHSP Claim form.

We use Interac e-Transfer to accept payment for the Registration Fee due, which is a very convenient and secure payment method. Since we are registered for Autodeposit, there is no security question required.

Just login to your business financial institution and use the Interac e-Transfer option to send the payment to:

Name: INTENDO BENEFITS
Email Address: benefits@intendo.ca

* Your payment will be matched with your registration based on your business name.

Also remember to select the option to add us as a recipient to your Payee List to facilitate future payments for claims.

Section D - Authorization

Recording my name below serves as a legally binding electronic signature and confirms that:
1. All information provided in this form is accurate and true to my knowledge.
2. I am authorized to act on behalf of the Plan Owner identified in Section A.
3. I have read and agree to the PHSP Terms listed in Section B.
4. I agree to paying the applicable registration fee listed in Section C.

Plan Owner Authorization

Register

IBA PHSP Registration Form

Section A - General Information

Annual Benefit Coverage Limits by Category
* If no limits are specified, the default will be 'Unlimited'

Section B - PHSP Terms (Please read carefully)

Section C - Registration Fee

Section D - Authorization

Registration Summary