MaxBen New Group Notification MaxBen New Group Notification MaxBen New Group Notice "*" indicates required fields Group Information Group Name*Policy Number*Effective Date* MM slash DD slash YYYY Number of Lives*Locations*Select all that apply. Alberta British Columbia Manitoba New Brunswick Newfoundland and Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Preferred Language*Select all that apply. English French Organization's Main Contact* First Last Email* Phone* Plan Information Johnston Group Business Development Director* First Last Advisor* First Last Email* Phone*MaxBen Plan & Rate* Maximum Benefit EAP (effective Jan. 1, 2026) Max MM – Premium Max DB – Premium (EAP only) Max DB – ASO/FFS (Standard) Rate $3.75 pepmSub-division*SelectMid Market (MM)Defined Benefit/Direct Billing (DB)Canadian Hospitality and Lodging Plan (HL)Tricor (TC)Rate (pepm)*Intervention Rate ($/hr)*Admin Rate (pepm)*Group Renewal Month*SelectJanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecemberForm Submitted by* First Last Email*
