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Please note:

Available Benefits may vary for a variety of reasons including industry, # of staff, family content, etc.
Please allow 1-2 business days for your Pooled Program quote summary.
Please complete to the best of your abilities, and leave blank what is unknown or does not apply.

Home based?

Yes

No

Associated / subsidiaries covered:

Yes

No

Employee(s) absent due to disability:

Yes

No

Employees currently traveling outside Canada?

Yes

No

Employees work min. 20 hours weekly:

Yes

No

Seasonal Employees ( 9 month min):

Yes

No

Employees covered by WCB:

Yes

No

Independent contractors:

Yes

No

Employer Contribution (%) :

Current Employee Benefit plan?

Yes

No

Reason for requesting quote

If you have a current plan, please attach the following if available:

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

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