Mail or fax (604.324.1762) to Promedent Administration Inc.
Please include a void cheque from the business bank account.



Head Office, 2066 Qualicum Drive, 1st Floor, Vancouver, BC, V5P 2M2
Tel 604.327.2022   Fax 604.324.1762
(hereinafter called "Promedent")


Legal Business Name: ______________________________________________ Incorporated? __ Yes   __ No
Business Address: ______________________________________________  
City: ____________________________ Province: _______________ Postal: _______________
Telephone: ____________________________ Fax: ____________________________
Email Address: ______________________________________________
(hereinafter called "the Employer")

The Employer hereby contracts with Promedent to reimburse medical and/or dental expenses that qualify as medical expenses under subsection 118.2(2) of the Income Tax Act, and are incurred by eligible partners or employees.

The Employer is responsible to ensure expenses are eligible and within an individual's annual limit. Any unused entitlements or excess expenses cannot be carried forward or back to other years.

The Employer will hold harmless Promedent, its Directors and employees, who accept no responsibility or liability for any damages, penalties or assessments of income tax to the Employer or to its employees that may arise from entering into the Promedent PHSP, a "cost-plus" Private Health Services Plan.

The employer authorizes Promedent to communication with the company and its employees via email and/or phone

The Employer authorizes Promedent to notify the Financial Institution to electronic funds transfer (hereinafter called "EFT") a one-time registration fee of $150.00 plus GST/HST (as applicable by province) (GST# 89758 4314 RT0001).

The Employer authorizes Promedent to notify the Financial Institution to EFT the variable amount of an approved claim, plus a claim fee, and issue an EFT to the employee. The claim fee for EFT is currently $50.00 (or 1% of claim for claims totalling $5000+), or $80.00 (or 1% of claim for claims totalling $8000+) for manual cheques, plus GST/HST (as applicable by province). Claims totalling $25,000+ will be subject to audit. A 2% plus tax processing fee will apply. Promedent reserves the right to change this fee in the future, and either party may cancel, in writing, this authorization at any time.

Withdrawal amount an EFT may not exceed each time $______________ from my (our) account.

 Branch Number:  Institution Number:  Account Number:




 Banking institution name:


Claim period for the employer shall be .

Signed at: ________________________________
    (City / Province)

Signature: ________________________________

Print Name: _______________________________

Title: ____________________________________

Date: __________________________________

Signature*: ______________________________

Print Name*: _____________________________

Title*: ___________________________________
* If second signature is required on your business bank account.