Build Your Own Benefits Plan Use our industry-leading Quote Request Form Create the plan(s) you would ideally like for us to quote, containing a minimum of 3 benefits lines Order Number Please note: Available Benefits may vary for a variety of reasons including industry, # of staff, industry etc. We will do our best to quote as close as possible to your requested options and may suggest alternatives. Please allow 5 – 7 business days for your custom quote summary. If a rush timing is required, please let us know and we will try to accommodate depending on workflow. Producer Name Desired Effective Date Company Name Address City / Province / Postal Code Mailing Address (if different from above) Telephone Fax Email Website Describe nature of business # of employees related to owner Home based? Yes No Years in business Associated / subsidiaries covered: Yes No Employee(s) absent due to disability: Yes No Employees work min. 20 hours weekly: Yes No All eligible employees participating: Yes No Employees currently traveling outside Canada? Yes No Seasonal Employees ( 9 month min): Yes No Employees covered by WCB: Yes No Independent contractors: Yes No Employer Contribution (%) : 25% 30% 35% 40% 45% 50% 55% 60% 65% 70% 75% 80% 85% 90% 95% 100% Select the Priority of each below, ranking 1-7 with 1 being highest. Life Insurance 1 2 3 4 5 6 7 Drugs 1 2 3 4 5 6 7 EHC 1 2 3 4 5 6 7 Vision 1 2 3 4 5 6 7 Dental 1 2 3 4 5 6 7 WI 1 2 3 4 5 6 7 LTD 1 2 3 4 5 6 7 Current Employee Benefit plan? Yes No Current Insurance Carrier Check all Current Benefits that apply: Life Life AD&D AD&D Dep Life Dep Life Drugs Drugs EHC EHC Vision Vision Dental Dental WI WI LTD LTD # of carriers in the past 5 years: Reason: Reason for requesting quote Broker approached Renewal Changing plan design Price Last billing statement attached: Yes No To follow Upload Statement Copy of current Benefit booklet: Yes No To follow Upload Booklet Copy of most recent Renewal: Yes No To follow Upload Recent Renewal
