Personal Information
Client Profile
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Group ID
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Certificate ID
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Group Name
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Division Class
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My Profile
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First Name
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Last Name
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Date of Birth
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Age
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Phone Number
Phone Number must be 10 digits
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Phone Extension
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Mobile Number
Mobile Number must be 10 digits
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Email Address
Please specify a valid email address.
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Address
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Language
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City
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Province
State
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Country
Canada
USA
Other
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Zip Code
Postal Code
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Dependent Listing
| Name | Date of Birth | Relationship | Benefit Start Date |
Benefit End Date |
COB
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Benefit Coverage
| HSA | Health | Dental | Drug | Travel | Wellness | Vision | Hospital |
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Family
Couple
Single
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Family
Couple
Single
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Family
Couple
Single
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Family
Couple
Single
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Family
Couple
Single
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Family
Couple
Single
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Family
Couple
Single
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Family
Couple
Single
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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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