Group Benefits Group Benefits Request for QuotationFull legal business name *Contact Name *Email Address *Address (Number, Street, Suite)CityProvinceselect oneABBCMBNBNLNSNTNUONPEQCSKYTPostal CodeBusiness DescriptionLength of time in business (min. 6 months)Current # of Full time Employees# of contract Employees# of Employees related to ownerAny Employees not actively at work?YesNoProvide DetailsAre all employees covered by WCB?YesNoWho is not coveredDoes the group currently have coverage?YesNoName of carrier# of years with current carrierPlan Design: Class ALife InsuranceYesFlat $OR Multiple of salaryDependent LifeYesLong Term DisabilityYesShort Term DisabilityYesExtended Health CareYesEHC coinsurance (excluding drugs, hospital and vision)80%90%100%OtherEnter %Drug Coverage (Drug card- Pays direct drugs)YesDrug Coinsurance80%90%100%OtherEnter %Drug Maximum$3,000$5,000$10,000UnlimitedParamedical CoverageYesCalendar year maximums per practitoner$250$300$350$400$500$750$1,000Annual CapYesNoEHC – Other ServicesYesSelect all applicableHospitalSemi-privateVision$__ Maximum (every 2 calendar years)Orthopedic shoes and orthoticsIn-Canada medical travelEnter AmountDental CareYes■ BasicCoinsurance80%90%100%OtherEnter %Annual Maximum$500$1,000$1,500$2,000$3,000UnlimitedRecall Exam6 months9 months12 months■ Major Restorative (minimum 3 lives)Coinsurance50%60%70%80%Maximum$500$1,000$1,500$2,000$3,000Combined with basic■ Orthodontia (minimum may not be available with some insurers and at certain employee levels)Coinsurance50% Maximum (lifetime)$1,000$1,500$3,000Additional Plan Designs and Options/NotesPlease include alternatives to the above plan design as well as any additional features you would like to see not covered above. Submit
