Please
complete & Fax Back to the attention of
Daniel
La Tour of JustinCase. JustinCaseInsurance.com
From:____________________________________
FAX TOLL FREE TO:1-888-637-2636
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?
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Fax to:Daniel La Tour: at: 1-888-637-2636
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Group Benefits Quotation
Request
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Employee
Name |
Gender M
/ F |
Birth
Date |
Occupation |
Annual
Salary |
Starting
Date with Company |
Covered
for |
Coverage
required S
= Single F
= Family W
= Waive * | |||||
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WCB |
EI |
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