Employer/Company Name: Contact Person:     Address: City: Province:  AB BC MB NB NF NS NV NW ON PE PQ SK YU Postal Code:   Telephone No: Ext: Fax No:  Email: Tentative Effective Date of Coverage: Number of Full-Time Employees:   Waiting Period for New Employees:   30 days 60 days 90 days 120 days Selected Plan Type: $10,000 Plan   Yes No    # of Employees   $25,000 Plan   Yes No    # of Employees   $50,000 Plan   Yes No    # of Employees 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.

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