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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)

 

 

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Revised: March 28, 2019