The Application Form
($200 set-up fee must accompany this form)
*required fields Note: please use your TAB key to navigate.
Company Name *
Company Address * City *
Province * Postal Code *
Contact Name *
Contact Phone * Contact Fax *
Contact E-mail Address *
Incorporated ? Y  N *
# of Employees  * Corporate Year-End  *
Accountant's Name  *
Accountant's Email  *
Accountant's Phone #  *
Trust Effective Date Today's Date
  (must be 1st of current month)
Would you like to add out-of-province / catastrophic health (OOPCAT) coverage? Y  N *
  (mandatory for unincorporated entities)
Were you referred to us by a licensed broker? If so, will you please provide us with their contact information?
Name Phone
Address Email

AVP Health & Welfare Trust

222, 855 - 42 Avenue SE
Calgary AB T2G 1Y8
Questions?

Call: 403.214.3213 or 888.214.3211
Toll Free Fax: 866.213.5514
E-mail: info@bizflex.ca
www.bizflex.ca