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Employee Group Benefits
Name:
Address:
City:
Province:
Postal Code: (X1Y 2Z3)
Phone Number: (123-456-7890)
Fax Number: (123-456-7890)
Email Address: (xxx@yyyy.zzz)
What is the exact nature of your business?
How many years has your company been in business?
 
Are there any subsidiaries or affiliates to be covered?
Yes No
Are all eligible employees participating in this plan?
Yes No
Are there any employees currently disabled, or disabled in the past 5 years?
Yes No
What percentage of your employees are related?
  %
Is the employer willing to contribute at least 50% toward the cost of this plan?
Yes No
Do you, or have you ever had, group insurance coverage?
Yes No
If yes, please complete the following:
Who is your current, or most recent, insurance carrier?
When did your coverage begin with your current insurance carrier?
Have you been with any other insurance carriers in the past 5 years?
Yes No
Will this plan include coverage for partners or sole proprietors?
Yes No
What areas of protection are most significant to you and your employees?
(included in the base plan are Basic employee life , accidental death & dismemberment and dependent life if applicable)
 Short–term Disability  Extended Health Care
 Long–term Disability  Dental Care
 Life-Flat amount  Critical Illness
 Life–Salary based  Confidential Counseling
 
 

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