Personal Information
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Client Profile
Group ID
Certificate ID
Group Name
Division Class
My Profile
First Name
Last Name
Date of Birth
Age
Phone Number
Phone Number must be 10 digits
Phone Extension
Mobile Number
Mobile Number must be 10 digits
Email Address
Please specify a valid email address.
Address
Language
City
Province
State
Country
Canada
USA
Other
Zip Code
Postal Code
Dependent Listing
Benefit Name
Effective Date
Termination Date
Coordination Of Benefits (COB)
Benefit Coverage
Benefit Name
Benefit Status
Effective Date
Termination Date
Wellness Release
I understand that should I agree to participate in the wellness initiative that claim information provided to ClaimSecure, in its capacity as a provider of health care benefits, may be used to provide me with additional resources to assist me in improving/maintaining my health, as described below. It is further understood that no individual information will be shared with Air Canada.
I understand that as part of this initiative I may receive communications regarding health related benefits and services that may be of interest to me as a result of this wellness initiative. I may also be made aware of programs and health educational events in which participation is voluntary. Finally, I understand that my decision to participate (or not) in the wellness initiative will in no way compromise my eligibility for any company sponsored benefit program.
I understand that as part of this initiative I may receive communications regarding health related benefits and services that may be of interest to me as a result of this wellness initiative. I may also be made aware of programs and health educational events in which participation is voluntary. Finally, I understand that my decision to participate (or not) in the wellness initiative will in no way compromise my eligibility for any company sponsored benefit program.
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