Customize a Benefits Plan Please enable JavaScript in your browser to complete this form. - Step 1 of 2Name *FirstLastEmail *Phone *Province/Territory *Newfoundland Nova Scotia New Brunswick Prince Edward Island QuebecOntarioManitoba Saskatchewan Alberta British Columbia YukonNorthwest Territories Nunavut Preferred Language English Français Plan Type *Individual Couples Single Parent Family Group Legal Status of Entity PersonSole Proprietorship Partnership Corporation Co-Operative Association Non-ProfitEntity NameWebsite / URLDo You Currently Have a Group Benefits Plan?NoYesWhen is its Renewal Date?Employee Census Benefits Booklets for All Classes Rate History Report (Last 3 Years)Claims & Premium Paid History Report (Last 3 Years)Number of Year in Operation 0 Years 1 Years 2 Years 3 Years 5 Years 10+ Years Nature of Operations Date of Birth *Is There Currently Anyone Taking Prescription Medication?NoYesAre You Currently Taking Prescription Medication?NoYesDetails of PrescriptionsGenderFemale Male OtherSmoking Habits Cannabis Tobacco Chewing Tobacco OccupationAnnual IncomeDate of Birth - SpouseGender - SpouseFemale Male OtherSmoking Habits - SpouseCannabisTobacco Chewing Tobacco Occupation - SpouseAnnual Income - Spouse Number of Children Number of MembersNumber of EmployeesAre All Employees Covered by Employment Insurance?YesNoPercentage of Employees Not Covered by Employment Insurance 5%10%25%50%75%100%Are Any Employees Covered by Workers Compensation?YesNoPercentage of Employees Covered by Workers Compensation5%10%25%50%75%100%Percentage of Employees Related to OwnerNone10%25%50%75%100%Number of Employees/Members 1 Year Ago Percentage of Employee Turn-Over from 1 Year Ago0%5%10%25%50%75%100%Percentage of Seasonal EmployeesNone10%25%50%75%100%Are there any independent contractors seeking coverage?NoYesWhat Percentage of the Workforce are Independant Contractors?5%10%25%50%75%100%Are there Unions Involved?NoYesAre There Commissioned Employees?NoYesAll Insured - Date of Birth, Gender, Occupation, Annual Income NextLife Insurance ($)This pays out a lump sum tax-free benefit in the event of your passingLife Insurance ($) - Spouse Life Insurance ($) - ChildrenDisability Benefits (% of Income)None10%25%33%40%50%60%70%MaximumWhat percentage of your monthly income would you like to insure from disability?Disability Benefit Period 1 Year 2 Years 5 Years To Age 65 In the event of a disability, for how long would you like to receive benefits?Disability Waiting Period14 Days 30 Days 60 Days 90 Days 120 Days In the event of a disability, how long can you wait before starting to receive benefits? Disability Benefit (% of Income) - Spouse What percentage of your spouse's monthly income would you like insure from disability?Disability Benefit Period - Spouse 1 Year 2 Years 5 Years To Age 65In the event of a disability, for how long would your spouse like to receive benefits? Disability Waiting Period - Spouse 14 Days 30 Days 60 Days 90 Days 120 DaysIn the event of a disability, how long can your spouse wait before starting to receive benefits?Critical Illness Coverage ($)This pays out a lump sum tax-free benefit in the event that you get diagnosed with a life threatening condition Critical Illness Coverage ($) - Spouse Critical Illness Coverage ($) - Children Accidental Death & Dismemberment ($)This pays out a lump sum tax-free benefit in the event that you die accidentally or if you lose a limb Accidental Fracture None $5,000$10,000This benefit provides for a lump sum payment in the event of a fracture suffered Accidental Death & Dismemberment ($) - Spouse This pays out a lump sum tax-free benefit in the event that you die accidentally or if you lose a limb Accidental Fracture - Spouse None$5,000$10,000This benefit provides for a lump sum payment in the event of a fracture suffered Accidental Death & Dismemberment ($) - ChildrenThis pays out a lump sum tax-free benefit in the event that you die accidentally or if you lose a limb Accidental Fracture - Children None $5,000$10,000This benefit provides for a lump sum payment in the event of a fracture suffered Accidental Loss of Use ($)This benefit provides compensation in cases of accidental loss of hearing, sight, speech or use of limbs.Accidental Loss of Use ($) - Spouse This benefit provides compensation in cases of accidental loss of hearing, sight, speech or use of limbs.Accidental Loss of Use ($) - Children This benefit provides compensation in cases of accidental loss of hearing, sight, speech or use of limbs.Dental Benefits None Basic Enhanced This benefit provides reimbursement for ongoing and unexpected cost relating to oral care Prescription Benefits NoneBasic Enhanced This benefit provides reimbursement for ongoing and unexpected prescription costs Vision Care Benefits None Basic Enhanced This benefit provides reimbursement and discounts for ongoing and unexpected vision care related expenses Emergency Travel Health Insurance None Trips of 15 Days or Less Trips of 30 Days or Less Trips of 30+ DaysCovers unexpected costs in the event of health emergencies when outside your province of origin Hospital Allowance ($)None$25$50$75$100This is a daily allowance if you become hospitalized Hospital Allowance ($) - SpouseNone$25$50$75$100This is a daily allowance if your spouse becomes hospitalized Post Accident AdaptionYes NoThis benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident Post Accident AdaptionNone Individual OnlySpousal This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident Post Accident AdaptionNoneIndividual Only Entire Family This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident Post Accident AdaptionNoneIndividual OnlyCouple Only Entire Family This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident Medical Expenses Due to Accident Yes NoThis benefit provides reimbursement for medical expenses in the event of an accident Medical Expenses Due to Accident None Individual OnlySpousal This benefit provides reimbursement for medical expenses in the event of an accident Medical Expenses Due to Accident None Individual OnlyEntire Family This benefit provides reimbursement for medical expenses in the event of an accident Medical Expenses Due to Accident None Individual Only Couple Only Entire Family This benefit provides reimbursement for medical expenses in the event of an accident NameSubmit Comments Comments are closed.
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