FBC HSA Enrollment

STEP 1: Owner & Company Details

Business Owner



Becomes the login username

mm/dd/yyyy

Example format: 403-123-4567

Dependant


Enter in mm/dd/yyyy format

Add dependant

5 digit FBC member number


Your legal business name

Determines what HSA products are available or required




Format Example: T2V 1X4

Example format: 403-123-4567

Alternate Plan Admin



Becomes the login username
​For assistance, please call​ ​toll-free​ ​1(844)​ ​FBC-DESK​ ​(844-322-3375)​.  Also, check out ​​our support center.

STEP 2: Healthcare Spending Account Setup


The benefit year based on any 12 month period.

Incorporated Company Annual Limits
Your annual limit is an amount you choose that is reasonable to cover to your health and dental expenses. Typical FBC members use a 10,000 annual limit however, any reasonable amount can be used. 

Any amount can be entered.

Any amount can be entered.
Sole Proprietor/Partnership Annual Limits
Your annual limit is an amount you choose that is reasonable to cover to your health and dental expenses. Typical FBC members use a 10,000 annual limit however, any reasonable amount can be used. 

$1500 max.

$1500/adult and $750/child max. (Ex:  2 Adults & 1 Child = $3,750 max)
InsurPak for Incorporated Companies (Optional)

(Single: $29.99 / mo., Family: $39.99 / mo.)​ Coverage ends at 65 years of age.
Direct Debit Information
Please print a copy of this completed form after submission and mail it along with a void cheque to:

National HealthClaim Corp.
335 58th Avenue SE
Calgary, AB
Canada T2H 0P3

Monthly Debit Authorization Form:  I (we) authorize National HealthClaim and noted Financial Institution to withdraw funds from my (our) business account for the purpose of paying FBC InsurPak premiums.  A debit in paper, electronic or other form may be drawn on my (our) account beginning the 15th day of the month after the enrollment has been signed. This agreement may be cancelled by either me (us) or National HealthClaim in writing, with at least 2 weeks (14 days) prior to the first day of the following month. I (we) also understand that should any withdrawal not clear my (our) account for reason of insufficient funds, National HealthClaim will automatically attempt to withdraw these funds within 10 days of the returned item without prior notification.

FBC InsurPak coverage is effective the first day of the month following the receipt and approval by National HealthClaim.  I authorize National HealthClaim to process a monthly debit on my (our) account for the amount determined by the number of single and family employees on the system by the first day of each month.
InsurPak for Sole Proprietors or Partnerships (Required)

(Single: $29.99 / mo., Family: $39.99 / mo.)​ Coverage ends at 65 years of age.
Direct Debit Information
Please print a copy of this completed form after submission and mail it along with a void cheque to:

National HealthClaim Corp.
335 58th Avenue SE
Calgary, AB
Canada T2H 0P3

Monthly Debit Authorization Form:  I (we) authorize National HealthClaim and noted Financial Institution to withdraw funds from my (our) business account for the purpose of paying FBC InsurPak premiums.  A debit in paper, electronic or other form may be drawn on my (our) account beginning the 15th day of the month after the enrollment has been signed. This agreement may be cancelled by either me (us) or National HealthClaim in writing, with at least 2 weeks (14 days) prior to the first day of the following month. I (we) also understand that should any withdrawal not clear my (our) account for reason of insufficient funds, National HealthClaim will automatically attempt to withdraw these funds within 10 days of the returned item without prior notification.

FBC InsurPak coverage is effective the first day of the month following the receipt and approval by National HealthClaim.  I authorize National HealthClaim to process a monthly debit on my (our) account for the amount determined by the number of single and family employees on the system by the first day of each month.

STEP 3: Plan Authorization

By checking the box above, the business agrees to provide a Health Spending Account for its employees and will pay for all account funding and administration fees as required. This enrollment form establishes a contract of Insurance (copy available online for Company Administrator).

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