Group Benefits Request Page - Online Form

Please fill out the form below. Do not forget to click on the submit button once done. We will respond to you shortly.

Part 1
Company Name:
Years in Business:
Email Address (that we may use to contact you):
Tel. Number (if email not specified or you prefer us to contact you by phone):
Do all employees work at least 24h per week? YESNO
Are your employees covered by Worker's Compensation? YESNO
Are any of your employees seasonal? YESNO
Are there independent contractors seeking coverage? YES NO
Are there any employees regularly working and traveling outside Canada? YES NO
Will this plan include coverage for partners or sole proprietors? YES NO
What is the most important aspect of a group benefit plan for you? PriceService
Financial Stability of Insurance Company
What areas of protection are most significant to you and your employees? Death Disability Healthcare Dentalcare
Confidential Counseling
Who is your current insurance carrier?
When did your coverage begin with your current carrier?
Have you been with any other insurance carrier in the past 5 years? If Yes, specify.


Part 2

Employee First Name Last Name DOB Hired Province Sex Hours Salary Pay Schedule Commission Dependant Life Health Dental Single/Family