Name of Organization (legal name) (required)
Street (required)
City (required)
Province (required)
Postal Code (required)
Business Telephone (required)
Your Email (required)
Name of Decision Maker (required) Title
Plan Administrator Title
Nature of Business
How many months has this business been in operation?
How many full-time employees? (minimum 25 hrs/week)
How many full-time employees did you have last year?
Number of employees related to the owner
Are any employees not actively at work due to accident or sickness YesNo
Do you curretnly have a benefit program? YesNo
If so, what is your current carrier
Other plan options, including disability coverage may also be applied for. Please indicate here if we should contact you regarding other plan options.
Life AD&DDependent Life
Plan Design
Description
Life and AD&D
$25,000 of Group Life Insurance, and an additional $25,000 of Accidental Death and Dismemberment Insurance
Dependent Life
$10,000 Spouse $5,000 for each dependent child
Please select one.
Plan 1Plan 2
Extended Health Care Plan Design 1
Unlimited overall maximum
Drug Plan 80% plan
Professional Services @ 80%
Extended Health Care Plan Design 2
Drug Plan 100% plan
Professional Services @ 100%
Optional.
Plan 1Plan 2Not at this time
Dental Care Plan Design 1
Maximum $1,000/year
Basic & Supplementary @ 80%
2 per calendar year
Dental Care Plan Design 2
Basic & Supplementary @ 100%
Name Sex Birthdate Hire Date Occupation Province Coverage - EHC Coverage - Dental Earnings Frequency Hours Per Week
