Health and Dental Employee Enrolment

  • Doctors of BC Health and Dental Plan

    Employee Enrolment Form

  • INSTRUCTIONS FOR EMPLOYER: Please complete the following application to enrol a new employee onto your clinic's plan.

    Upon submission, Doctors of BC Health and Dental administrator will review and send the document to your employee to complete dependent and beneficiary information

  • Sponsoring Physician/Employer Information


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  • Personal Information - Employee


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  • Date of Birth*
     / /
  • Gender*

  • Province/Territory of Residence: Please note that residents of Quebec are not eligible for coverage

  • Plan Selections

    To be completed by Sponsoring Physician/Employer
  • What plan tier for Extended Health and Dental are you enrolling the employee in?

  • Please note: the plan tier must be the same for all employees. Doctors of BC will adjust the enrolment form prior to signature to match the tier chosen for Employees under the Member Agreement.

  • Employees must be working at least 20 hours per week in order to be eligible for this plan. If an employee is not working 20 hours per week, they may join the plan without proof of health within 90 days of working 20 hours per week.

  • Group Life Insurance & Accidental Death & Dismemberment Benefit*
  • Long Term Disability*

  • Please note: coverage greater than $1,000 will require the employee to complete an Evidence of insurability form and be approved by the carrier before coverage will be effective

  • The amount of LTD selected should not exceed 85% of gross monthly earnings.

  • Date of Employment (or date working 20 hours per week)*
     / /

  • Coverage becomes effective on the first day of the month coincident with or immediately following three months of continuous employment at 20 hours or more per week, provided the application form is received by that date. The Sponsoring Employer may request the waiting period be waived

  • Do you want to waive the waiting period for this employee?

  • Life and AD&D Beneficiary Designation

  • In the event of my death, I name the person(s) below to receive the policy proceeds. To the extent permitted by Law, I reserve the right to change the beneficiary(ies) named below.

  • If designating a beneficiary who is a minor who lacks legal capacity, please appoint a Trustee below who will receive the minor's beneficiary share.

  • Extended Health and Dental 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 application is made at a later date.

  • Will the employee be enrolling any dependents?*
  • 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*
     / /
  • 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 healthcare plan. Please do not include the ones that are not covered from the e-application and answer the question as "Yes".

    You may enroll 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 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 refuse health and dental benefits for you and/or your dependents as a result of this other policy?*

  • 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. 

    Please Note: If you waive coverage for yourself, you will still be enrolled in Long Term Disability, and Group Life/AD&D benefits

  • I refuse Extended Health and Dental coverage as I and/or my dependents are insured under my spouse's group policy.*

  • If you wish to add this coverage at a later date, such as if your dependents coverage terminates under the policy indicated above, satisfactory evidence of insurability for you and/or your dependents will be required. 

  • Authorizations

  • Employer (Sponsoring Physician) Acknowledgements:

    I understand that if the Employee is not actively working on the date coverage would normally become effective, it is my responsibility to notify the Doctors of BC Health & Dental Plan Administrator as coverage will not become effective until the Employee returns to work.

  • Submission and Next Steps

  • Submission Date*
     / /
  • Should be Empty: