Appendix C: Family Members

This form constitutes an amendment to the Health Spending Account (HSA, Private Health Services Plan, PHSP) Registration Agreement. Use as many copies of this form as required to provide a complete list of the family members of the proprietor. All family members must have the same household mailing address as the Planholder shown on the Registration form. Unrelated (arms-length) employees of the business must be entered on “Appendix A: Eligible Employees”.
Unincorporated business owners are restricted by the Canada Revenue Agency (CRA) when selecting the Class of Coverage. The owner, spouse, and related adults of the household can claim a maximum of $1500 per year under current CRA rules, and will be assigned Class B. Minor children (under 18 years of age) can claim up to $750 per year and will be assigned Class C. Unrelated (arms-length) employees of this business as listed on Appendix A: Eligible Employees can be provided with any coverage amount designated by the unincorporated business owner. However, the unincorporated business owner and spouse cannot have coverage that is greater than the lowest amount assigned to an unrelated (arms-length) employee.
NOTE: Attach a VOID cheque(s) for reimbursement by Direct Deposit

Family Member Information

Identification

Choose one
Attach a VOID cheque for reimbursement by Direct Deposit