Get a Group Benefits Quote Please enable JavaScript in your browser to complete this form.Name *FirstLastEntity NameLegal Status of Entity PersonSole Proprietorship Partnership Corporation Co-Operative Association Non-ProfitNumber of Year in Operation 0 Years 1 Years 2 Years 3 Years 5 Years 10+ Years Nature of Operations Number of EmployeesProvince/Territory *Newfoundland Nova Scotia New Brunswick Prince Edward Island QuebecOntarioManitoba Saskatchewan Alberta British Columbia YukonNorthwest Territories Nunavut Email *Phone *Do You Currently Have a Group Benefits Plan?NoYesDesired Benefits Extended Health Coverage Basic Prescription Drug Coverage Enhanced Prescription Drug Coverage Basic Dental Coverage Enhanced Dental Coverage Orthodontic Coverage Vision Care Hospitalization Travel Insurance Accidental Death and Dismemberment Short Term Disability Long Term Disability Life Insurance Critical Illness Insurance Basic Paramedical Specialist Coverage Enhanced Paramedical Specialist Coverage Health Spending AccountPension Plan Group RRSP Deferred Profit Sharing Plan Pension Plan When 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)Are 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 I authorize that insurance offers be sent to me electronicallyCommentSubmit Comments Comments are closed.
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