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  Group Benefits

Request for Quotation

Contact Information

* represents mandatory fields

Name *

Company Name *
Postal Code *
Phone Number *
E-mail *
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


Pease check, if requested  



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  

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, major services and orthodontic services combined]


  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 Natalia

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



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Revised: March 21, 2018