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Contact Information |
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* represents mandatory fields |
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Name * |
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Company Name * |
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Address* |
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City* |
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Province |
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Postal Code * |
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Phone Number * |
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E-mail * |
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Website |
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Best Time
to Call |
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About Company |
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Nature of business
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Type of company |
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Number of years in
business |
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Number of Full Time
Employees |
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Number of Part Time
Employees |
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Number of Seasonal
Employees |
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Number of Contract
Employees |
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Are 50% or more of
the employees from the same family?
Yes
No |
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Are any employees
or dependants currently hospital confined or
otherwise disabled
or handicapped?
Yes
No |
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Are all employees
covered by WSIB ? |
Yes
No |
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Do you have Group
Benefit Plan? |
Yes
No |
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Who is the current
carrier for Group Benefit Plan?
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Start Date |
dd/mm/yyyy |
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Pease
check, if requested |
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▼ |
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Basic Life and Accidental Death and Dismemberment |
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Flat
amount:
OR |
Formula amount:
X
Annual Salary |
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Dependent Life
(Spouse: $10,000 Child
: $5,000)
Yes
No |
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Short Term Disability |
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Elimination period:
accident
sickness (optional)
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Benefit period:
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Benefit Amount:
* Employee pays
premium for non-taxable benefit
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Long Term Disability |
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Elimination period:
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Benefit period:
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Benefit Amount:
* Employee pays
premium for non-taxable benefit |
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Extended Health Care |
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Co-insurance (insurance company pays):
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Paramedical services:
Annual maximum per paramedical discipline
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Hospital Accommodation (private or semi-private)
Yes
No |
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Prescription Drug |
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Co-insurance (insurance company pays):
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Deductible per
prescription
Annual limit :
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Vision Care |
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Maximum every 24 months |
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Dental Benefits |
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BASIC SERVICES |
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Co-insurance (insurance company pays):
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Deductible per year (single/family) |
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Recall Visit -
once every |
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Annual maximum |
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[Annual
maximum applies to basic services only or where available, basic, major
services and orthodontic services combined] |
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MAJOR SERVICES
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Include major services at 50%
co-insurance
Yes
No |
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ORTHODONTIC SERVICES
[Major services must also be selected] |
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Include orthodontic services at 50% co-insurance
Yes
No
(for
children 18 years of age and under)
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Critical Illness |
