Promedent PHSP - List of Approved Employees

Mail or fax (604.324.1762) to Promedent Administration Inc.
Please include a void personal cheque for each employee eligible for reimbursement

Approved List of Employees for The Promedent Plan™ (attach another page if necessary)

EMPLOYEE INFORMATION	CLAIM LIMIT
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:
Employee Name: SIN: Address: City: Prov: Postal: Phone: Email:

*Promedent will notify the employee of their enrolment.
Legal Business Name: Authorized Signature: ____________________________________	Date: ________________________

PROMEDENT ADMINISTRATION INC.
Head Office, 2066 Qualicum Drive, 1st Floor, Vancouver, BC, V5P 2M2
Tel 604.327.2022 Toll-free 1.866.563.5423
Fax 604.324.1762 info@promedent.ca
www.promedent.ca