Group Benefits quotes

1-877-443-0101

Group Benefits

Request for Quotation

	Contact Information
Name *	* represents mandatory fields
Company Name *
Address*
City*
Province
Postal Code *
Phone Number *
E-mail *
Website
Best Time to Call

About Company
Nature of business
Type of company
How long the company has been in business* (minimum 6 month)
Number of Full Time Employees
Number of Part Time Employees
Number of Seasonal Employees
Number of Contract Employees
Are 50% or more of the employees from the same family?	Yes No
Are any employees or dependants currently hospital confined or otherwise disabled or handicapped?	Yes No
Are all employees covered by WSIB ?	Yes No
When do you want to start this plan?	dd/mmm/yyyy
Do you have Group Benefit Plan now?	Yes No
Who is the current carrier for Group Benefit Plan?
Renewal Date of your current plan	dd/mmm/yyyy

	PLAN DESIGN
▼

	Basic Life and Accidental Death and Dismemberment
	Flat amount: OR	Formula amount: X Annual Salary
	Dependent Life (Spouse: $10,000 Child : $5,000) Yes No
	Short Term Disability
	Elimination period: for accident for sickness (optional)
	Benefit period:	Benefit Amount: * Employee pays premium for non-taxable benefit
	Long Term Disability
	Elimination period:
	Benefit period:	Benefit Amount: * Employee pays premium for non-taxable benefit
	Extended Health Care
	Co-insurance (insurance company pays):
	Paramedical services: Annual maximum per paramedical discipline
	Hospital Accommodation (private or semi-private) Yes No
	Prescription Drug
	Co-insurance (insurance company pays):
	Deductible per prescription Annual limit :
	Vision Care
	Maximum every 24 months
	Dental Benefits
	BASIC & SUPPLEMENTARY SERVICES
	Co-insurance (insurance company pays):
	Deductible per year (single/family)
	Recall Visit - once every
	Annual maximum
	[Annual maximum applies to basic services only or where available, basic and major services ]
	MAJOR SERVICES
	Include major services at 50% co-insurance Yes No
	ORTHODONTIC SERVICES [Major services must also be selected]
	Include orthodontic services at 50% co-insurance Yes No (for children 18 years of age and under)
	Critical Illness

Additional Information, Notes and Questions

Please confirm your E-mail

We will contact you within one business day. Depending on the plan design selected by you, additional information about your group will be requested.

If you have any questions or need help to fill out the form call

at 416-493-0101 (toll free 1-877-443-0101)

Revised: March 28, 2019