Health and Dental Plan - Member Agreement

  • Doctors of BC Health and Dental Plan Member Agreement with Trustees

  • This application will take approximately 20 minutes to complete.

    To assist in the completion of your form, please ensure you have the following:

    1. Your banking details - if you have not previously submitted banking details to Doctors of BC, you will need to upload a void cheque or attach a direct deposit authorization form. Corporate accounts will require a certificate of incorporation to be submitted as well

    2. Your preferred coverage tiers (Essential, Enhanced, Premier). Details of these tiers can be found on our website.

    3. Full names, dates of birth and knowledge of provincial medical insurance coverage for all employees you are enrolling

    4. Full names, dates of birth and knowledge of provincial medical insurance for all dependents you are enrolling.

  • Eligibility and Type of Application

  • To be eligible to participate in the Doctors of BC Health and Dental plan, you must be a Canadian resident, who has submitted the application in a province or territory other than Quebec, and not a resident of Quebec at the time the application is submitted.

    Please contact our team at insurance@doctorsofbc.ca so we may refer you to an alternative provider.
  • I am submitting a:*
  • Is the sponsoring physician changing?*
  • I would like to enrol the following under my Health and Dental plan (check all that apply):*
  • What is your date of birth?*
     - -
  • Unfortunately, you do not qualify to apply for Health and Dental under the Health Benefits Trust Fund Plan at this time. Physicians must be actively at work and under age 65 in order to apply for new coverage. If you would like Doctors of BC to contact you when you have returned to work, please email us at insurance@doctorsofbc.ca and include your expected return to work date.

     

  • Member Details

  • Do you want to set up the Health and Dental plan under a corporation or different business name?*
  • Format: (000) 000-0000.

  • PHYSICIAN ELIGIBILITY DECLARATION

  • Please select which applies to you:
  • Retirement Date*
     - -

  • TRAINING COMPLETION OFFER

    Please review and tick off the following statements to determine if you qualify for the offer.

  • TRAINING COMPLETION OFFER ELIGIBILITY DECLARATION*
  • Date you completed residency or fellowship training*
     - -

  • You want coverage to start on June 1st. Unfortunately, this is not the correct form to complete as any applications effective June 1st are enrolled first with Canada Life.

    Please use the Doctors of BC HBTF Member Agreement to enrol.

  • You qualify for the Training Completion Offer. You do not need to provide evidence of insurability. A 50% discount will be applied to your Health and Dental premiums for the first 12 months. At the end of the discount period, your premium will change to the full premium.

  • You do not qualify for the Training Completion Offer. Evidence of insurability will be required. Our administrators will send you the medical questionnaire required by Manulife.

  • I understand that evidence of insurability (proof of good health), in the form of a writen questionnaire, for me, my eligible dependents and my employees (if any) will be required.

  • List of Participating Physicians and Eligible Employees

    Schedule A

  • Schedule A is meant to capture all employees and physicians who are working for the clinic participating in the Health and Dental plan. Do not include your dependents in this section.

     

    Note (COST-PLUS): The Income Tax provisions for an ELHT(Section 144.2(2) (d) allows the Trust to provide Cost-Plus benefits to the employee, the employee’s spouse or common-law Partner, and an individual who is related to the employee and either a member of the employee’s household or financially dependent on the employee for support. (ie. child, grandchild, parent, grandparent, sibling, niece, nephew etc). This amount will include covered expenses for your eligible dependents as defined under the Income Tax Act. Please ensure you discuss the Optional Cost Plus Plan with your Accountant or Financial Advisor prior to selecting Cost Plus to ensure your eligibility.

  • Note: To comply with employer health and dental insurance rules, each employee is assigned an employee 'class.' All members of a class must have shared characteristics. The Doctors of BC Health and Dental plan has a "Physician" class and an "Employee" class. If you add Cost-Plus for your employees, you may have different classes for employees, but they must be distinct.

    Note: This e-application includes a physician enrolment form to enrol yourself. A separate Health and Dental Enrolment Form from each eligible employee and participating physician (other than yourself) is required. Additional information may be required by the Health and Dental Plan Administrator or by the insurance company during the application process; and

  • You are eligible for the Training Completion Offer, but have selected "Premier" tier. Evidence of Insurability is required for the Premier tier. 

    In order to qualify for 50% discount, you must complete your evidence of insurability within 8 weeks of submitting this application. 

    If you are declined for the Premier tier, you are guaranteed to enrol on the Enhanced Tier.

  • Date of Birth*
     / /
  • Do you want to add cost-plus for Physician 1?*

  • Unincorporated doctors are currently eligible to enrol in Cost-Plus. However, based on recent legal recommendation to align the program with CRA guidelines, effective January 1, 2027, unincorporated doctors will no longer be eligible for the Cost-Plus feature, and it will be terminated from their Health and Dental plan.

    If you wish to proceed with adding Cost-Plus feature until January 1, 2027, leave your answer above as “Yes.” If you do not wish to enrol in Cost-Plus in 2026, please change your answer to “No.” If you become incorporated at a later date, you will be invited to add the feature to your plan during an annual open enrolment between November 1-30.

     

  • You have indicated that Physician 1 has fewer than 4 people in their family. Unfortunately at this time, that family size is ineligible to add Cost-Plus, please change the Cost Plus answer above to "No"

  • Do you want to add Health and Dental for another participating Physician?*
  • Physician 2 Date of Birth*
     / /
  • Do you want to add cost-plus for Physician 2?*

  • You have indicated that Physician 2 has fewer than 4 people in their family. Unfortunately at this time, that family size is ineligible to add Cost-Plus, please change the Cost Plus answer above to "No"

  • Do you want to add Health and Dental for another participating Physician?*
  • Physician 3 Date of Birth*
     / /
  • Do you want to add cost-plus for Physician 3?*

  • You have indicated that Physician 3 has fewer than 4 people in their family. Unfortunately at this time, that family size is ineligible to add Cost-Plus, please change the Cost Plus answer above to "No"

  • Employee 1 Date of Birth*
     / /
  • Do you want to add cost-plus for Employee 1?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Do you want to add cost-plus for Employee 2?*
  • Employee 2 Date of Birth*
     / /
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 3 Date of Birth*
     / /
  • Do you want to add cost-plus for Employee 3?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 4 Date of Birth*
     / /
  • Do you want to add cost-plus for Employee 4?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 5 Date of Birth*
     / /
  • Do you want to add cost-plus for Employee 5?*
  • Do you want to add Health and Dental for another participating Employee?*
  • Employee 6 Date of Birth*
     / /
  • Do you want to add cost-plus for Employee 6?*

  • You indicated that not all applicants listed on this application are covered under a Provincial/Territorial healthcare plan. Please do not include the ones that are not covered by a Provincial/Territorial healthcare plan in the e-application.

    You may enrol employees and dependents within 90 days of them gaining coverage under a provincial/Territorial healthcare plan. Contact insurance@doctorsofbc.ca and we can assist with enrolment.

     

  • Designated Authorized Person

    Schedule B

  • Doctors of BC will accept signed instructions from you, the Sponsoring Physician, or a Designated Authorized Person you appoint, for certain administrative changes.

    A Designated Authorized Person ("DAP") may:

    • Add new employee coverage
    • Add dependents to enrollee's coverage,
    • Terminate employee coverage
    • Authorize bank account changes (if the DAP is also an authorized signatory on the bank acount);
    • Communicate with Doctors of BC and receive information about employee enrolment, invoices, and bank accounts.

    Doctors of BC will accept instructions from either your DAP or you (the Sponsoring Physician). The Sponsoring Physician may change the DAP at any time by completing a new Schedule B. Only one DAP can be authorized at a time.

  • Do you want to name a Designated Authorized Person ("DAP")?*

  • Direct Debit Authorization Form

    Health and Dental Plan and Optional Cost-Plus Plan

  •
  • I (we) hereby authorize Doctors of BC as Administrator of the Trust Fund to withdraw my monthly Plan premium directly from my (our) bank account.*
  • Monthly Premium Withdrawal (and Cost-Plus funding, if applicable)- Bank Account Details*
  • Does this bank account require two signatures?*

  • Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Cost-Plus Claim deposits - I am enrolling in Cost-Plus for myself*
  • Rows
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof
  • Cost-Plus Claim Deposits - I am enrolling in Cost-Plus for my employees*
  • Browse Files
    Drag and drop files here
    Choose a file
    Cancelof

  • Physician Enrolment

    • The applicant (and dependents) must be covered under a Provincial Health Care Plan (ie BC MSP) to be eligible to participate in this plan.
    • All applicants must be under age 65 at time of enrolment.
    • Applicants must be actively working at time of enrolment
  • Date of Birth*
     / /
  • Gender*
  • Insurance Plan Tier*
  • Are you enrolling any dependents?*

  • Dependent Information

  • An “eligible dependent” is defined as any person who is:

    • Your legal spouse, or a person with whom you have lived for one year and have publicly represented as your spouse.
    • Your unmarried dependent child(ren) under age 22, or under age 25 if a full-time student attending an educational institution recognized by the Canada Revenue Agency (CRA) and entirely dependent on you for financial support.

    Dependent(s) not listed will be subject to proof of good health if they are enrolled at a later date.

  • Who are you enrolling as dependents on this plan?*
  • Spouse Date of Birth*
     - -
  • Child 1 Date of Birth*
     - -
  • Child 2 Date of Birth*
     - -
  • Child 3 Date of Birth*
     - -
  • Child 4 Date of Birth*
     - -
  • Child 5 Date of Birth*
     - -
  • Child 6 Date of Birth*
     - -
  • Are all dependents listed above, covered by a Provincial/Territorial healthcare plan (i.e. BC MSP, OHIP, etc)*

  • You indicated that not all dependents listed on this application are covered under a Provincial/Territorial health care plan. Please do not include dependents who are not covered by a Provincial/Territorial health care plan on this e-application.

    You may enrol dependents within 90 days of them gaining coverage under a provincial/Territorial healthcare plan. Contact insurance@doctorsofbc.ca and we can assist with enrollment.

     

  • Do you have any other dependents ages 22-24 who are full-time students?*
  • Do you have any other dependents ages 22-24 who are full-time students?*

  • Refusal of Benefits

  • Are you and/or your dependents insured under a different group health & dental insurance policy?*
  • Do you want to decline participation in Doctors of BC health and dental benefits for you and/or your dependents because you are insured with another plan?*

  • Complete this section if you wish to refuse Extended Health Care and Dental Care for yourself and/or your dependent(s).

    This will be allowed only if similar benefits are currently in force under your spouse’s group policy.

    If you wish to add this coverage at a later date, statisfactory proof of evidence of insurability health for you and/or your dependent(s) will be required. 

  • I refuse Extended Health and Dental coverage as I and/or my dependent(s) are insured under a different health and dental insurance plan.*
  • Effective Date of Coverage*
     / /

  • Physician Enrollment Acknowledgement

  • I am authorized to disclose information about my spouse and dependents in order to enroll them in the plan

    By enrolling in this Plan, I authorize the following:

    Manufacturers Life Insurance Company (“Manulife”), its agents and service providers, its re-insurers and their service providers to collect, use and disclose relevant information about me to underwrite, administer and adjudicate claims

    Doctors of BC (my plan sponsor) to collect, use, and disclose information about me, my spouse, and dependents necessary for enrollment and administering the plan.

       I affirm that myself and/or my dependents are covered by a provincial/territorial health plan

    I have expressly requested to complete the application in English. I acknowledge that pursuant to the language laws in Quebec, Manulife will provide me with a French and English version of my policy and all further documents related to the application and policy will be drawn up in English exclusively.

    I declare the information above is accurate and true.

  • Agreement Terms

    Between the Doctors of BC member and The Doctors of BC Health Benefits Trust Fund Trustees (the "Trustees")

  • 1. A reference in this agreement to:

    (a) “I” or to “me” or to “Member” or to “Employer” means the physician described above, whether an individual, corporation or partnership, and if I am not an employer then “I” or “me” refers to me as a physician who is participating in the Health and Dental Plan;

    (b) The “Administrator” shall mean the Doctors of BC as administrator of the Health Benefits Trust Fund;

    (c) The “Health and Dental Plan” means:

    (i) for a physician who is participating in the Health and Dental Plan, the extended health care and dental benefits provided by the Trustees, plus the optional Cost-Plus Portion of the Plan; and

    (ii) for Eligible Employees of the Physician (excluding however an employee who is a physician), the extended health care, dental, life, disability and accident benefits apply; and the Cost-Plus Portion of the Plan is optional, but if elected, must apply to all Eligible Employees;


    (d) “Cost-Plus Portion of the Plan” means, in reference to the Health and Dental Plan:

    (i) the maximum annual reimbursement allowed under the applicable legislation, or what the physician has set out in Schedule “A”, whichever is lower, for each physician who is participating in the Health and Dental Plan; and

    (ii) the maximum annual reimbursement which the physician has set out in Schedule “A” (if no amount is specified, then the amount is $500 in a calendar year for each Eligible Employee of the physician for which Cost-Plus Portion of the Plan has been added; and if Cost-Plus Portion of the Plan has not been added or if no employees of the physician are listed in the list of Eligible Employees, then the amount is nil).


    e. “Eligible Employees” shall have the meaning as set out in the Health and Dental Plan Booklet of the Trust Fund in effect from time to time.


    2. I understand that this is a legal agreement between the Trustees and me. I apply to Doctors of BC Health Benefits Trust Fund (the “Fund” or “Trust Fund”) to participate in the Health and Dental Plan. This Member Agreement sets out the terms and conditions under which I, as a physician, may participate in the Health and Dental Plan provided by the Fund.

    3. The participation of each Eligible Employee and the physician in the benefit plans offered from time to time by the Fund is effective from the first day of the month immediately following receipt and acceptance of this Member Agreement and all other required enrolment forms, or on such later date as is determined by the Trustees. I understand that there may be medical evidence requirements to obtain some of the benefits in the Health and Dental Plan, and satisfactory completion of those medical evidence requirements may be necessary for an Eligible Employee or physician to participate in those benefits.

     

  • 4. I understand that:*
  • I understand that:*

  • 8. I have completed Schedule “A” of this Member Agreement listing the Eligible Employees (if any), the participating physician(s) and the other necessary information that the Fund needs.

  • 10. I understand that the Plan Summary/Details brochure of the Trust Fund and the Health and Dental Plan Booklet, which may be updated, revised, replaced or supplemented in the future by the Trustees, and the rest of this Member Agreement sets out other terms and conditions of the agreement between the Trustees and me, as the physician. I will also consult with my tax or other professional advisor for other important information, details and restrictions which may apply to me, as an employer.

    11. I will also consult with my tax or other professional advisor for additional important information details, and restrictions that may apply to me as an employer. If enrolled in Cost-Plus program, I have consulted a tax advisor to confirm my suitability for this program, including but not limited to, enrollment, limit amounts selected and participation of my employees, if applicable.

  • GENERAL TERMS


    By participating in the Doctors of BC Health and Dental plan, administered by the Health Benefits Trust Fund, I agree that:

    1. I have expressly requested to complete the applicationin English. I acknowledge that pursuant to the language laws in Quebec, Manulife will provide me with a French and English version of my policy and all further documents related to the applciaiton and policy will be drawn up in English exclusively.
    2. I have received a copy of the Fund’s Trust Agreement (or I have reviewed a copy on the Doctors of BC website). I am familiar with the terms and conditions of the Fund’s Health and Dental Plan and the Fund’s Trust Agreement.
    3. I will abide by all terms and provisions of the Health and Dental Plan, the Fund’s Trust Agreement and the decisions of the Trustees.
    4. I will pay the required Trust Fund benefit plan premiums on behalf of myself, my spouse, dependents and participating Eligible Employees.
    5. If I am enrolling Eligible Employees in the Health and Dental Plan, I confirm that all of my Eligible Employees are listed on Schedule “A”. By not listing employees on Schedule “A”, I confirm that I do not have any Eligible Employees or have chosen not to enroll any employees in the plan. 
    6. I will promptly notify the Fund in writing should the employment of any participating Eligible Employee terminate for any reason, if I employ new Eligible Employees, or if the Sponsoring Physician of a clinic changes.
    7. I am aware that upon approval by the Trustees, this Member Agreement will come into effect on the date specified by the Fund through its Administrator, provided this Member Agreement and the Plan application forms are complete. I also understand that to be eligible for some of the benefits, the insurer must also give its approval. I understand the Trustees may terminate this Member Agreement by written notice to me. I agree to continue participation in the Fund and the Health and Dental Benefits Plan until such date that the Trustees process a completed termination form or the physician is no longer an active member of Doctors of BC. I will send a request of termination by fax or email to:
       

    Fax:       (604) 638-2909
    Email:    insurance@doctorsofbc.ca 

    In any event that either party changes address, written notice shall be given to the other party.

  • Submission and Next Steps

  • Please click Submit when you are ready. A Health and Dental administrator will review your application for completeness and send you a DocuSign envelope for your final review and signature.

  • Submission Date*
     - -
  • Should be Empty: