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Wellness Plan Application

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Wellness Plan Application

For Existing PC Metro Clients

If you already have a PC Metro Health Spending Account (HSA), simply select “Yes – I want to add the Wellness Account to my existing HSA” at the top of the application.

Completing this form ensures your Wellness benefits are set up correctly and administered in accordance with CRA, privacy, and reporting requirements.

"*" indicates required fields

Instructions for Completing This Form

Complete all applicable sections.
Submit the completed and signed form to initiate setup.
Contact us for questions about terminology or plan details.

Notes:

Ensure at least one employee classification is defined.
Employer representatives must sign the declaration.

1. Application Details

Do you currently have a PC Metro Health Spending Account (HSA)?*

Yes – I want to add the Wellness Account to my existing HSA

No – I’m interested in a stand-alone Wellness Plan

Client Name*

First Last

Full Company Legal Name*

Address*

Street Address City Province Postal Code

Nature of Business*

Phone*

Email Address*

Signing Officers Name & Title*

Plan Administrator Name*

Administrator Communication Email

Effective Date*

MM slash DD slash YYYY

(The plan may be backdated to January 1 of the current calendar year, if desired.)

Business Type:

Incorporated/Professional Corporation*

Yes

Non-Incorporated with Arms-Length Employees*

Yes

1a. Initial Owner Enrollment Information

This information is used to complete the initial plan setup. Additional employees and dependents may be enrolled once the plan is active.

Owner / Primary Participant Name*

Date of Birth (DD/MM/YYYY)*

MM slash DD slash YYYY

Email Address*

Email*

Personal information collected is used solely for plan administration and handled in accordance with applicable privacy legislation.

Note: Employees and dependents may be added after plan setup through the online portal.

2. Eligibility & Compliance

Employees must be actively working in the business.
Coverage applies to all employees in each class equally.
All employees must sign a privacy waiver before claims are shared with the employer. Only amounts and categories are disclosed — no personal health information.

Equivalency Rules

When determining employee classification, the following factors may be considered to ensure consistency across roles:

Responsibilities
Education
Income Range
Work Hours
Years of Service
Job Title / Group

Note: This helps the employer group employees to the appropriate classes for plan administration, if needed.

3. Wellness Plan Coverage & Employee Classification

Class: A1

Description / Eligibility: Owner/Executives

Annual Wellness Limit per Participant for Class A1 ($)

Notes

Class: B

Description / Eligibility: Employees

Annual Wellness Limit per Participant for Class B ($)

Notes

Class: C

Description / Eligibility: Other (Optional)

Annual Wellness Limit per Participant for Class C ($)

Notes

Family coverage, if applicable, is subject to the annual limit shown.

Here Are Some Examples of Included Wellness Services

Gym / Fitness Memberships
Wellness Coaching
Weight Loss Programs
Smoking Cessation Aids
Stress Management Programs
Children’s Dance Classes and Dance Costumes
Other Extracurricular Activities (sports, arts, wellness-related programs)
Other non-medical wellness services

Note: Examples are provided for clarity. The plan may cover other non-medical wellness-related activities at the administrator’s discretion.

4. Claim Submissions & Cut-Off Rules

Submission Methods: Employees may submit claims through the secure online portal. Some service providers may submit claims directly on behalf of the employee, with authorization.
Supporting Documentation: Receipts or proof of service must be provided for all claims. Incomplete documentation may delay reimbursement.
Submission Deadline: Claims must be submitted within 365 days of the service date.
Annual Limit Application: Reimbursements are applied to the plan year of the service date, even if paid in a subsequent year.

Taxable Benefit:

All reimbursements under this wellness plan are considered a taxable benefit and will be reported on the employee’s T4 in the year paid.

Year-End Reporting

PC Metro will provide the employer with a report early in the new year outlining each employee’s total wellness benefit used.
This ensures that any amounts reimbursed in the prior year can be accurately included in the employee’s T4.
Employees and employers can use this report for record-keeping and tax purposes.

5. Financial Summary & Fees

Wellness Plan Setup & Initial Credit:

One-time setup fee: $210
Initial credit balance for wellness claims: $100

Administration Fees & Adjudication:

Fee Type:
Monthly Administration Fee

Rate:
$2.50 per employee

Notes:
GST included

Fee Type:
Adjudication Fee

Rate:
10% on paid claims

Notes:
GST applies to this fee only; not to the reimbursed claim amounts

Payment Options

E-Transfer
Pre-Authorized Debit (PAD)
Online Bill Payment: Set up PC Metro as a bill payee via your corporate online banking site. Use the plan number assigned to you as your account number when making payments.

6. Application Declaration

Consent*

I confirm the wellness plan will be administered according to the information provided.*

Consent*

I confirm all employees are eligible for this benefit.*

Consent*

I understand that failure to meet requirements may affect administration of the plan.*

Referral Details (Optional)

Have you been referred to PC Metro?*

Yes

If yes, please provide the name of the person or organization who referred you:

Employer Representative

Name*

First Last

Title

Company Name*

Signature*

Date*

MM slash DD slash YYYY

Note: This form is for Wellness Plans only. If you are looking to apply for a Health Spending Account (HSA), please use the HSA Application.