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Flexible Health Benefits: John Crosser

Flex Benefit Program – Why?– Allows each employee to:

• select the type of benefits best matching their priority (Risk, Health/Dental, and Retirement)

• select the level of coverage according to their individual circumstance (Health/Dental)

• health benefits waived only if spouse is currently covered elsewhere

• benefits rolled into Group RRSP should Health & Dental Benefits be waived

• receive the maximum tax benefit and relief as an employee of Coverall

Employee Base Plan• Life & ADD Insurance: Level $100,000• Short Term Disability: 1st Day/8th Day 17 Weeks• Long Term Disability: 121st Day Wait/ to age 65• Critical Illness: Level $25,000

Group Plan Flex Benefits Health & Dental• 3 Different Levels of coverage to choose from

Flex Benefit Program - Components

Employee Base PlanLife Insurance/ADD $100,000 Premium $ 34.00

Short Term Disability $ 1000 Premium $ 96.25

Long Term Disability $ 5000 Premium $ 96.00

Critical Illness $25,000 Premium $ 14.80

Base Plan Monthly Premium $241.05

Assumed Monthly Income: $3000. Rates may vary based on actual age & income

Note: Optional Coverage Available (Life & Critical Illness)

Affordable Plan Beneficial Plan Comprehensive Plan

Drug Deductible

Dispensing Fee. As set by individual pharmacy

Dispensing Fee. This will vary depending on pharmacy.

Dispensing Fee. This will vary depending on pharmacy.

Drug Coverage

50% on the 1st $400/yr, 80% on the next $500, then 100% of the remaining

50% on the 1st $400/yr, 80% on the next $500, then 100% of the remaining

100%

Drug Card

Pay direct at pharmacy. Pay direct practitioner (chiropractor, massage therapy,

physio, naturopath, etc…)

Pay direct at pharmacy. Pay direct practitioner (chiropractor, massage therapy,

physio, naturopath, etc…)

Pay direct at pharmacy. Pay direct practitioner (chiropractor, massage therapy,

physio, naturopath, etc…)

Other Coverages100% Benefit

Semi-Private hospital room, ambulance costs, eye exams, orthopaedic shoes, hearing aids,

medical appliances, etc…

Semi-Private hospital room, ambulance costs, eye exams, orthopaedic shoes,

hearing aids, medical appliances, etc…

Semi-Private hospital room, ambulance costs, eye exams, orthopaedic shoes,

hearing aids, medical appliances, etc…

Practitioner $500 per practitioner per calendar year $500 per practitioner per calendar year $500 per practitioner per calendar year

Travel Benefit

$5,000,000/yr, 60 days per trip out of province coverage

$5,000,000/yr, 60 days per trip out of province coverage

$5,000,000/yr, 60 days per trip out of province coverage

Dental Deduction

Single member pays first $25/yrFamily member pays first $50/yr

Once the deductible has been paid 80% coverage to max. $1500/yr per family

member (if chosen)

There Is No Deductible

Once the deductible has been paid 80% coverage to max. $1500/yr per family

member (if chosen)

There Is No Deductible

Once the deductible has been paid 80% coverage to max. $1500/yr per family

member (if chosen)

Dental Coverage

80% Basic Coverage. This includes root canals (endodontics/periodontics)

80% Basic Coverage. This includes root canals (endodontics/periodontics)

50% Major Coverage. This covers crowns, caps and bridges

80% Basic Coverage. This includes root canals (endodontics/periodontics)

50% Major Coverage. This covers crowns, caps and bridges

50% Orthodontics This covers children under 17 Maximum $1500 Lifetime

Single Rate $103.56 $122.16 $176.73

Couple Rate $184.20 $210.76 $288.69

Family Rate $233.14 $283.63 $381.09

Employee Premium with Affordable Plan

Single Couple Family Covered by Spouse

Employee Base Plan Cost: $241.05 $241.05 $241.05 $241.05

Employer Credit $150.00 $150.00 $150.00 $150.00

Health Plan Premium ($103.56) ($184.20) ($233.14) $ 0.00

Employee Portion Health $ 0.00 $ 34.20 $ 83.14 $ 0.00

RRSP Benefit $ 46.44 $ 0.00 $ 00.00 $150.00

Taxable Benefit $ 46.44 $ 0.00 $ 00.00 $150.00

Total Employee Premium $ (241.05) or

$8.04/day

$ (275.25) or $9.18/day

$ (324.19) or $10.81/day

$ (241.05) or $8.04/day

Employee Premium with Beneficial PlanSingle Couple Family Covered by

Spouse

Employee Base Plan Cost: $241.05 $241.05 $241.05 $241.05

Employer Credit $150.00 $150.00 $150.00 $150.00

Health Plan Premium ($122.16) ($210.78) ($283.63) $ 0.00

Employee Portion Health $ 0.00 $ 60.78 $133.63 $ 0.00

RRSP Benefit $ 27.84 $ 0.00 $ 00.00 $150.00

Taxable Benefit $ 27.84 $ 0.00 $ 00.00 $150.00

Total Employee Premium $ (241.05) or $8.04/day

$ (301.83) or $10.06/day

$ (374.68) or $12.49/day

$ (241.05) or $8.04/day

Employee Premium with Comprehensive Plan

Single Couple Family Covered by Spouse

Employee Base Plan Cost: $241.05 $241.05 $241.05 $241.05

Employer Credit $150.00 $150.00 $150.00 $150.00

Health Plan Premium ($176.73) ($288.69) ($381.09) $ 0.00

Employee Portion Health $26.73 $138.69 $231.09 $ 0.00

RRSP Benefit $ 0.00 $ 0.00 $ 00.00 $150.00

Taxable Benefit $ 0.00 $ 0.00 $ 00.00 $150.00

Total Employee Premium $ (267.78) or $8.93/day

$ (379.74) or $12.66/day

$ (472.14) or $15.74/day

$ (241.05) or $8.04/day

Personal Benefit Selection

AffordablePlan

50/80/100% Pay Direct Drugs/ Disp Fee Deductible/100% other80%Basic/No Major Dental/$25/50 Deductible

Beneficial Plan

50/80/100% Pay Direct Drugs/ Disp Fee Deductible/100% other80%Basic/50% Major Dental/ Nil Deductible

ComprehensivePlan

80% Pay Direct Drugs/ Nil Deductible/100% other80%Basic/50% Major Dental/ Nil Deductible

The choice for level of coverage and cost for group benefits is now yours.

Indicate the type of benefit you require by placing an X in the appropriate box. When the form has been completed, place the original with the Group Enrolment form and submit it to your plan administrator/rep. We will provide a more detailed breakdown of the benefits and premiums tailored to your situation based on this information.

Employee Name: _____________________________ Age:__________ Annual Income:______________ Email Address: ___________________

My dependant status is: Single Dependant Covered by Spouse

I elect the following Dental and Extended Health Benefit Program. I understand the options chosen cannot be changed for two years from the effective date of my choice.

Employee Signature:___________________ Date:_________________

X Base Plan Optional Life/Critical Illness Coverage