Accountable Value Financial Services: Registration Form

Registration Form

Please fill out all the fields to register for a PHSP with Accountable Value Financial Services. Your information will be securely transmitted but not stored on our servers.

Step 1 of 7

Company Information
Please fill out the information about your company.
Company Name*
Company Status*
Are you incorporated/limited/corporation or a sole proprietorship
- Incorporated / Limited / Corporation
- Sole Proprietorship
Address*
Street Address Address Line 2 City Province Postal Code
Phone*
Email*
Effective Date*
This is when you would like the plan to be effective. It can be any date, we suggest the beginning of your current fiscal year or the beginning of the calendar year.
MM slash DD slash YYYY
Business Number
Please supply your business number.

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Coverage Information
This section deals with coverage for yourself and your employees.
Class Coverage*
A Class is what we call the limits you can impose on your employees. You can have an unlimited number of classes.
Class Name Class Amount
Class Coverage*
As a Sole Proprietorship, you are limited to $1500.00 per adult in the household and $750.00 per minor in the household. Anyone can claim from this "household total". If you have other employees, and want to create limits, you may do so, but the first 2 classes are reserved for the $1500.00 and $750.00 limits respectively. A Class is what we call the limits you can impose on your employees. You can have an unlimited number of classes.
Class Name Class Amount
Fiscal Year End*
Your fiscal year end is when you close your financial records for one year and file your taxes.
Fiscal Year End*
Your fiscal year end is when you close your financial records for one year and file your taxes.
Benefit Year Start*
Your benefit year usually starts on the first day after your fiscal year end OR the beginning of the year. You can set this to be any day you wish. If you have employees, we recommend a calendar year (Jan 01) because employees are used to that with benefits.
Benefit Year Start*
Your benefit year usually starts on the first day after your fiscal year end OR the beginning of the year. You can set this to be any day you wish. If you have employees, we recommend a calendar year (Jan 01) because employees are used to that with benefits.
Coverage Allotment*
You can set up the employees starting year whether you want to give them full benefits regardless of when they start; pro-rated amount to the day they start; or a specified amount (you will provide the amount).
Regular Benefit Year*
Here you can specify the employees typical benefit year and how you want their benefits calculated. You can specify: Annual Amount (they receive their benefits on Day 1); Monthly Accrual (they will receive 1/12 of their benefits at the start of every month); Quarterly Accrual (they will receive 1/3 of their benefits at the start of every benefit quarter); Semi-Annual Accrual (they will receive 1/2 of their benefits every 6 months).
Plan Style
We currently have 2 styles of plans Standard - We issue an invoice after each claim is submitted. : Pre-Payment - We will invoice you for 1/12 of your total coverage limits and hold at least 50% of this amount on account from month to month.

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Terms of Service
1. In accordance with Subsection 248(1) of the Income Tax Act, Accountable Value Financial Services Ltd. (hereafter known as AVFS) by this document establishes a “cost plus” Private Health Services Plan with the Company named in Part A. AVFS indemnifies the Covered Claimants of the Company for all Eligible Expenses for the agreed upon cost plus fee to be paid by the Company upon remittance of claim by the Covered Claimant.
2. The AVFS PHSP applies to all Eligible Expenses. For this agreement Eligible Expenses are those defined in Subsection 118.2(2) of the Income Tax Act. These are outlined in Canada Revenue Agency Interpretation Bulletin IT-519R2 - Medical Expense Tax Credit Folio.
3. The AVFS PHSP covers all employees as defined by the Company in Appendix A. The term Covered Claimant includes the employee, the employee’s spouse or any member of the employee's household with whom the employee is connected by blood relationship, marriage or adoption. There is no limitation by age. The Covered Claimant will be eligible for coverage from the effective dates established in Appendix A.
4. The Company will establish an effective date after which coverage is provided by the plan. This date can be as early as the beginning of the current fiscal year of the Company.
5. The Company may choose to offer this benefit plan to Covered Claimants in differing levels of sponsorship based on the position or critical importance of the employee within the firm. The Company may not limit participation in the AVFS PHSP based solely on position as a shareholder. The AVFS PHSP cannot be offered to one employee of a class while excluding an employee of the same class. For this plan the Company has established the following classes of sponsorship. The members of these classes are established in Appendix A.
6. AVFS will adjudicate each claim submitted to ensure the following:
  1. The expenses are Eligible Expenses as per section 2
  2. The claimant is a Covered Claimant as per section 3
  3. The maximum coverage limits and dates as authorized by the Company have not been exceeded
  4. The claim form has been properly completed, authorized and the corresponding payment has been received
7. Upon completion of the claim adjudication, AVFS will issue an Interac eTransfer re-imbursement for the total cost of the eligible expenses to the claimant.
8. AVFS will issue an Annual Client Statement to the Company to reconcile all claims for tax reporting at the end of the fiscal year.
*
- I have read and accept the above
Signature*
By typing your name, you are registering with Accountable Value Financial Services for a PHSP plan
Phone
This field is for validation purposes and should be left unchanged.

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Registration Form

Step 1 of 7

Company Information

Contact Information

Coverage Information

Employee Information

Referral

Registration Fee

Interac eTransfer

Cheque

Credit Card / Invoice

Waived by Referrer

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Terms of Service

Class Name	Class Amount

Class Name	Class Amount

First Name & Last Name	Street Address	City	Province	Postal Code	Phone Number	Email	Effective Date	Class Coverage	Employee or Spouse	Reimbursement Method (eTransfer / Cheque)