 |
| Name of company |
|
| Administrative Contact |
|
Title |
|
| Street |
|
| City |
|
| Province |
|
| Postal Code |
|
| Email |
|
| Phone |
Ext.
|
Fax |
|
| Comments |
|
 |
| How long has the business been operating?
|
| Nature of business
|
| Does an outside agency (e.g, government) fund 50% or greater of this business?
|
 |
| Please select the number of eligible employees
|
| Number of temporary workers
|
| Number of contract workers
|
| Number of seasonal workers
|
| Number of employees related to the business owner
|
| Is this business operating in a private home?
|
| Are any eligible employees represented by a union?
|
| Are workers covered by Workers Compensation
|
| Do all employees & their dependents reside and work in Canada?
|
| Number of employees not at work due to a serious or long term disability
|
| Are any employees involved in hazardous occupations?
|
 |
| Who is your current insurance carrier?
|
| When did your coverage begin with your current insurance carrier?
|
| Have you been with any other insurance carriers in the last 5 years? Yes
No
|
 |
| Tentative Effective Date
|
 |
| Select the benefits you would like to have included in the quote: |
|
Create my plan using 2 option classes
|
|
Class 1
|
Class 2
|
|
Life and AD&D |
Life and AD&D |
|
Dependent Life |
Dependent Life |
|
Short Term Disability |
Short Term Disability |
|
Long Term Disability |
Long Term Disability |
|
Extended Health |
Extended Health |
|
Dental |
Dental |
 |
 |
Employer Contribution Rate |
|
| Earnings
or Flat Amount
|
|
::] Dependent Life- Class 1 |
Employer Contribution Rate |
|
Spouse |
|
Child |
|
| Child |
 |
| Employer Contribution Rate |
|
Benefit Amount |
|
| Benefit Maximum |
|
| Benefit Period |
|
| First Day Hospital |
|
| Occupational |
|
 |
Employer Contribution Rate |
|
| Benefit Type
Flat %
Graded |
| Benefit Amount |
|
| Graded first $2,500 |
|
| Graded next $3,500 |
|
| Benefit Maximum |
|
| Qualifying Period |
|
| COLA |
|
| Definition of Disability |
|
 |
Employer Contribution Rate |
|
| Overall Coverage |
| Reimbursement |
|
| Deductible Amount |
|
| Drug Plan Options |
| Pay Direct
Yes
No |
| Deductible |
|
| Reimbursement |
|
| Drug Type |
|
| Drug Option |
|
 |
| Paramedical Services Annual Maximum |
|
| Paramedical Services Reimbursement |
|
| Hospital Benefit |
|
| Vision Care Benefit |
|
 |
Employer Contribution Rate |
|
| Deductible Amount |
|
| Recall |
|
| Basic |
Reimbursement
|
| Maximum
|
|
Major |
Reimbursement
|
| Maximum
|
|
Orthodontics |
Reimbursement
|
| Maximum
|
|
 |
Employer Contribution Rate |
|
| Earnings
or Flat Amount
|
 |
Employer Contribution Rate |
|
| Earnings
or Flat Amount
|
 |
Employer Contribution Rate |
|
Spouse |
|
| Child |
|
 |
| Employer Contribution Rate |
|
Benefit Amount |
|
| Benefit Maximum |
|
| Benefit Period |
|
| First Day Hospital |
|
| Occupational |
|
 |
Employer Contribution Rate |
|
| Benefit
Type
Flat %
Graded |
| Benefit Amount |
|
| Graded first $2,500 |
|
| Graded next $3,500 |
|
| Benefit Maximum |
|
| Qualifying Period |
|
| COLA |
|
| Definition of Disability |
|
 |
Employer Contribution Rate |
|
 |
| Reimbursement |
|
| Deductible Amount |
|
| Drug Plan Options |
| Pay Direct
Yes
No |
| Deductible |
|
| Reimbursement |
|
| Drug Type |
|
| Drug Option |
|
|
| Paramedical Services Annual Maximum |
|
| Paramedical Services Reimbursement |
|
| Hospital Benefit |
|
| Vision Care Benefit |
|
 |
Employer Contribution Rate |
|
| Deductible Amount |
|
| Recall |
|
| Basic |
Reimbursement
|
| Maximum
|
|
Major |
Reimbursement
|
| Maximum
|
|
Orthodontics |
Reimbursement
|
| Maximum
|
Complete and return the provided
employee data spreadsheet
- If the group has existing coverage through another carrier, we require
the past 3 years Renewal Reports, along with a copy of the current Employee
Booklet or Plan Design.
- Provide a copy of the most recent billing from current insurance
carrier.
Additional Information / Notes:
|
