Health & Dental Online Sign-up

Health Trust

Manulife Health and Dental

Enroll in Health Trust

Company Name:
Address:
City:		Province:	AB BC MB NB NF NS NT NU ON PE SK YT
Postal Code:
Key Contact Information: (this person will be the main contact person for your Health Trust account)
Salutation:	Dr. Mr. Ms. Mrs. Ms.
First Name:		Last Name:
Telephone:		Fax:
Email:
Enrollment Details:
Effective Date:
How would you like to receive your Registration documents?			Email Fax Mail
How would you like to receive your Invoices?			Email Fax Mail
How will payments be made to Hub Financial?			Select... Cheque Direct Banking
All employee claims will be paid by Electronic Funds Transfer (EFT). Click here for the enrollment form.
Would you like to use the Internet to manage your Account?			Yes No
Were you referred by a licensed Broker?			Yes No
If yes, Broker Name:		Telephone: