Client Information

Client Questions

Are there any Seasonal or Contract Employees?
If yes, please specify:
Are 50% or more of the employees from the same family?
If yes, please indicate relationship and if they reside in the same household:
Premium contribution basis in Percentage:
(The employer is required to pay a minimum of 50%)
Are all employees and owners covered by Workers Compensation (WSIB)?
Are there any disabled employees?
If Yes, please complete the following chart in full (the notes area at the end may also be used):

Employee Name Occupation Date of Disability Nature of Disability Prognosis Life Waiver Approved?
Employee 1:
Employee 2:
Employee 3:
Are you currently insured?
If yes, please indicate the following:

Are benefits being quoted the same as your current plan?
If not, explain why:
Experience and rates provided? (Please include the most current month and a minimum of two years (preferably three))