HealthPlus from CAPCORP Financial

HealthPlus Employer Information Form
Employer Name:
Administrative Contact for HealthPlus¹:
Address:
Phone:
Fax:
Email:
Fiscal Year End²:
CAPCORP Advisor:	(if unknown, one will be assigned to you)
How did you hear about us?

Notes:

*Please inform CAPCORP of any changes to contact information*

1. The Administrative Contact (AC) is the Employer's primary contact in regards to the funding of HealthPlus claims.

2. To be eligible to fund HealthPlus claims, the Employer must be an incorporated business.

rev. 09/Aug/2007




	CAPCORP 1050 Morrison Dr., 3rd Floor Ottawa, Ontario K2H 8K7 Toll-free: 1-800-267-1964 (or 613-226-1964) Fax: (613) 226-8402