Employee Benefits

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Broker Name if Applicable:
Broker Contact Number:
Broker E-mail:
   
Employer Name: *
 Address: *
 City/Town: *
 Postal Code:  *
 Province: *
 Phone Number:  *
 Fax Number:  *
 Email: *

 Contact Name   First:

 *

 Contact Name   Last:

 *
 Contact Position: *
 # of Full Time Employees: *
 # of Part-Time Employees:
   
 Renewal Date/Inception Date: *
   
 Years in Business: *
   
 Receive occasional correspondence
Employee Classification Structure:
If you have more than One (1) benefit classifications for your Companies employees please identify each class below:
Class A:         Class B:   
Class C:      Class D:   
Class E:      Class F:   
 

Benefit Plan Details

Life Insurance:

 
Class A:

 Flat amount of:  OR   X Earnings, to a maximum of: $

Amount of AD&D coverage: % of life insurance.
Is there life insurance for dependents?    Yes    No
If Yes, what is the amount of insurance for dependents? (Spouse/Child)
 
Is coverage the same for all Classes of employees?
If No, please indicate the differences in the attached box:
 

Weekly Income:
 
 Is there weekly income?    Yes    No
 If so, please fill out the following:
 Accident Waiting Period: Sickness Waiting  Period:
 Benefit Period: weeks  Maximum: $ per week.
 Percentage of Earnings: %
Taxable?  
Is coverage the same for all Classes of employees?
If No, please indicate the differences in the attached box:
 

Long Term Disability:
 
Is there LTD? Yes No
If so, please fill out the following:
 Waiting Period:  days  Maximum $ per month.
 Benefit Period: Taxable?
 Percentage of Earnings: % Two Year Occupational?
 Premium Offset Five Year Occupational?
Optional Benefits: Own Occupation To 65?
   
Optional Coverage COLA % commencing after years
 		  

 
Is coverage the same for all Classes of employees?
If No, please indicate the differences in the attached box:
 
Critical Illness Insurance:
 
Benefit Amount: $    
 
Is coverage the same for all Classes of employees?
If No, please indicate the differences in the attached box:
 

 Health Benefits:
 
How much is the annual deductible?
$ Single $ Family $ Single Parent $ Couple
How much is the annual Co-Insurance %?    EHS
Single Family Single Parent Couple
Catastrophic Only HSA Volumes:

$

Employers HSA Contribution $ Single $ Couple $ Family

 

Allotment Period
Rolling Type

 

 

 
Re-imbursement factors:  
  Prescription Drugs: %  Pay Direct Card: Yes No Deductible $per prescription Co-Insurance $%
  Hospitalization:Yes No Semi-Private: Yes No
  Paramedical Services:  % Maximum per year:  $
 Extended health Care: %    
Travel Plan: Yes No Maximum per trip: (always   1,000,000) $
Vision Care:  %  Maximum per 24 months: $
 
Is coverage the same for all Classes of employees?
If No, please indicate the differences in the attached box:
 

Dental Benefits:
 
Are there dental benefits?  YesNo
   
 Fill out the following only if you have dental benefits 
     
How much is the annual deductible?
$ Single $ Family $ Single Parent $ Couple
How much is the annual Co-Insurance %?   
Single Family Single Parent Couple
     
Re-imbursement factors: 
   
   
Recall visits:   
Annual Maximum (per year):   $
Major Restorative: % Maximum:   $ /year
Orthodontics: % Maximum: $ /lifetime
Is coverage the same for all Classes of employees?
If No, please indicate the differences in the attached box:
 

General:
 
Please indicate any special requests or specific coverage's which are not listed above (for example, if you want your plan to include lifestyle drugs for anti-smoking, sexual dysfunctions and weight loss drugs then you can mention that here.)

 
A maximum of nineteen (19) employees are allowed for a Quick Quote. If you have more than 19 employees send us an attachment with your company's employee details.

Click here to download an Excel spreadsheet which you can fill out and send as an attachment -

 
You must have a minimum of ten (10) employees if you want to classify your employees. Classifications are either "A" ,"B" or "C" and must be based upon occupational duties. For example, labour could be class B and management Class A. If you specify classes then you MUST describe the difference in coverage's in the section below the employees table.
All fields except employee earnings are required. Employee names can optionally be anything you want, as long as something is entered (e.g. 1, 2, etc.).
 
Name Gender Date of Birth
(mm/yyyy)		 Date Employed
(mm/yyyy)		 Earnings Occupation Coverage
Type 		 Classification
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
$  
 

Coverage Details for Classification: (only if you classified your employees)

 

Underwriting Details
 
Nature of your business operations?
How long in Business? years 
Reason For Marketing?
Renewal date of group policy? (mm/yyyy)
Name of Existing Benefits Insurer?
Do you require billing to more than one (1) division?
Are all eligible employees full time?
(minimum of 24 hours per  week)
Are any employees paid commission income?
Are any employees required to engage in any hazardous activities?
If Yes, please explain:
Are all employees covered by the Workers Safety Insurance Board?
If No, please explain:
Are all employees residents of Canada?
Have you been with your current carrier for two (2) years or more? (N/A for first-time cases)
Are any employees currently inactive due to injury, accident or illness? 
Please explain the disability particulars:

 

Claims Experience
Health Claims Information:
Health Claims Information: Current year Last Year Previous Year
Premium Paid: $ $ $
Claims: $ $ $
 
Dental Claims Information: Current year Last Year Previous Year
Premium Paid: $ $ $
Claims: $ $ $
Rate History: