Group Benefits Quote Form
For any questions and concerns please Contact a Group Benefits Specialist at (905) 597-5000 or email us at Benefits@3ifinancial.com
Section 1
Company Information (The company must have been in business for at least 6 months)
Company Name
*
Nature of Business
Address
*
Street Address
Street Address Line 2
City
Province
Postal Code
Contact Person
First Name
Last Name
Phone Number
-
Area Code
Phone Number
In Business Since
Year your Company First Opened
Do You Currently Have a Group Plan?
Yes
No
Please Upload Claims History and Rate History
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Present Carrier
*
Manulife
Sunlife
Blue Cross
Great West Life
Empire Life
Dejardins
Other
If Other, Please Specify
Effective Since
*
Number of Full Time Employees
*
Number of Part Time Employees
*
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Section 2
Benefits Information
Life and Accidental Death & Dismemberment
*
(Mandatory)
Benefit Options
*
$10,000
$50,000
$100,000
1x annual earnings
2x annual earnings
3x annual earnings
If Other, Please Specify
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Dependent Life
*
(Mandatory)
Benefits Options
*
$5,000 Spouse, $2,500 each dependent child
$10,000 Spouse, $5,000 each dependent child
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Extended Health Care (Optional)
Yes
No
Coinsurance
60% reimbursement
70% reimbursement
80% reimbursement
100% reimbursement
Benefits Maximum
$1000/year
$2000/year
$5000/year
Unlimited
Paramedical Practitioners
$300/practitioner/year
$500/practitioner/year
Vision Care
Only Eye Exam
$150/24 Months
$200/24 Months
$250/24 Months
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Dental Care (Optional)
Yes
No
Coinsurance (Basic Services Only)
60%
70%
80%
100%
Benefits Maximum
$1,000/year
$1,500/year
Major Services
50% Reimbursement
Benefits Maximum
$1,000/year
$1,500/year Combined with Basic Services
$2,000/year Combined with Basic Services
Benefits Maximum
$1,000 Lifetime
$1,500 Lifetime
$2,000 Lifetime
Annual Recall Options
6 Months
9 Months
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Short Term Disability (Optional)
Yes
No
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Long Term Disability (Optional)
Yes
No
Benefits Options
Payable for 5 Years
Payable to age 65
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Critical Illness (Optional)
Yes
No
Benefits Options
$10,000
$25,000
Other
If Other, Please Specify
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Section 3
Current Employee Data Please Fill in all the Fields or Upload an Excel File Below *[F (Family) S (Single) W (Waived)]
*
Employee Name
Gender
Date of Birth (YYYY/MM/DD)
Dependent Status*
Date Employed
Hours Worked Per Week
Job Title
Annual Earnings
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Upload Excel File Here
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Notes
Enter Message Shown
*
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