Cost Plus Enrolment / Change Form - Strive
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2COST PLUS
ENROLMENT / CHANGE FORM
Employer / Plan Section (to be completed by the plan administrator)
Company Name:
Division:
Policy No:
Enrol Employee (Plan effective date:_____________________ )
Add Dependant: (Effective date: _______________ )
Reinstate Employee (Plan effective date: _________________ )
Change Address
Terminate Employee (Termination date : _________________ )
Remove Dependant (Term. date: _______________ )
Employee/ Participant Details (to be completed by the employee)
Last Name:
First Name:
M/F:
Street Address:
City:
Province:
Postal Code:
Date of Birth: (mm/dd/yyyy):
Daytime Phone Number:
Coverage Status:
Single:
Couple:
Family:
Waived:
Dependant Details (to be completed by the employee)
(mm/dd/yyyy)
Spouse: Last Name:
First:
Sex:
DOB:
Child 1: Last Name:
First:
Sex:
DOB:
Child 2: Last Name:
First:
Sex:
DOB:
Child 3: Last Name:
First:
Sex:
DOB:
Child 4: Last Name:
First:
Sex:
DOB:
Please indicate the name of any disabled dependants:
Please indicate below, if dependants are full time students and over age 21.
Attach the registration letter, which confirms full-time enrolment.
Name of Over Age Student
College/University Attended
Enrolled From
Enrolled To
Cost Plus Enrolment/Change 09/16
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Parent category: Business