Please complete & Fax Back to the attention of

Daniel La Tour of JustinCase. JustinCaseInsurance.com 

 

  From:____________________________________

 

  FAX TOLL FREE TO:1-888-245-5505

 

 

Group Benefit Plan

 

1. What is the most important concerning your Group Benefit Plan?

 

 1 -important

 2 -somewhat important

 3 -not important

 

__Prescription drug care

__Accidental Death & Dismemberment

__Dependent Life Insurance

__Life Insurance Minimum Amount

__Life Insurance 1 X Salary

__Life Insurance 2 X Salary

__Life Insurance 3 X Salary

__Short Term Disability or wage loss replacement benefits (usually for the first 17 weeks)

__Long Term Disability or wage loss replacement benefits (up to age 65)

__Basic Dentalcare

__Major Dentalcare (Orthodontics)

__Healthcare Professionals Chiropractor, Psychologist, Physiotherapist, Nutrionist, etc.

__Hospital Semi-private room

__Vision Care

__Critical Illness Insurance

__Long Term Care/Home & Facility Care

__Voluntary Group RRSP Registered Retirement Savings Plan

__Voluntary Group RESP Registered Education Savings Plan

__Pet Care Insurance

 

To do our market analysis and recommendations, please provide us with the following information   (Please check mark)

 

2. Does the Company or Employer agree to contribute Annually towards the cost of the proposed Group Benefit Plan?

__Yes

__No

__25%

__50%

__100%

Other/Comments: __________________________________________________________________________________

 

3.  Are you currently insured by a Group Benefits Plan?

 

__Yes

__No

 

4.  If No, when do you want your Group Benefits in force?

 

MM/YY:  ____/____

 

5.  If Yes, who is the Insurance Carrier?

 

__GWL

__Manulife

__Empire

__Sun Life

__Other: _______________________________________________________

 

6.  Who is the Signing Officer to sign the Group Benefit Contract with the Insurer?

 

Contact Info:

 

Name:___________________________________________________________

 

Title: _____________________________________________________________

 

Email address: ________________________________________________________

 

Telephone number/Ext _______________________________________________________

 

7.  When is the next renewal?

 

MM/YY:  ____/____

 

8.  How many years insured by the Insurance Carrier?

 

__Less than 2 years

__Less than 5 years

__Other

 

Your Human Resources List of proposed Group Benefits Plan Participants, (Full-time Employees, Independent Contractors must be working at

 least 24 hr. per week and 9 months out of 12) Part-time employees.

 

9.  Is there a Union Agreement at work?

 

10.  Is there anybody on Disability Leave? Details please.

 

11.  Is there anybody on Maternity Leave? Details please

 

12.  Are all Group Participants Canadian Citizens, Landed Immigrants?

 

 

 

 

 

Fax to:Daniel La Tour:

at:    1-888-245-5505

Business Name:

 

Contact Name:

 

Address:

 

Title:

 

 

 

Phone:

 

 

 

Fax:

 

 

 

Email:

 

      

Group Benefits Quotation Request

 

Employee Name

Gender

M / F

Birth Date

Occupation

Annual Salary

Starting Date with Company

Covered for
Y / N

Coverage required

S = Single

F = Family

W = Waive *

 

 

D

M

Y

 

 

D

M

Y

WCB

EI