This form constitutes an amendment as Appendix C to the PHSP agreement. Use as many copies of this form as required to provide a complete list of household members of the unincorporated business owner to identify the eligible claimants for your PHSP. This form is only for family members of the sole proprietor. Unrelated employees should be included on Appendix A as a Covered Employee. All family members are presumed to have the same household mailing address as shown on the PHSP Registration Form.
Sole proprietors are limited by Canada Revenue Agency when selecting the Class of Coverage. These will be automatically assigned by Brock Health when the plan is opened. The owner, spouse and related adults of the household can claim a maximum of $1500 per year and will be assigned as Class B. Minor children (under 18 years of age) can claim up to $750 per year and will be assigned as Class C. Unrelated employees can be provided with any coverage amount designated by the business owner. However, the business owner and spouse cannot have coverage that is greater than the lowest amount assigned to an unrelated employee.
