Equote Form for Group Benefits

Name of Business (required)
Operating Business Name

Number of years in business: (required)
Number of years your company has been in business.

What is the nature of your Business?: (required)
What type of Industry does your Business focus on?

Number of Owners: (required)
How many Owners in your Business?

Has your Business ever had an Employee Benefits Plan?: (required)

If yes, which Insurance Company?:

Renewal Date: (required)

Date when coverage is needed: (required)

First & Last name: (required)

Job Title: (required)

Business Address: (required)

City: (required)

Province: (required)

Postal Code: (required)

Phone: (required)

Fax:

Email: (required)

Website:

Number of Full Time Employees: (required)
24+ hours worked per week

Benefits you are most interested in: (required)
 Extended Health Care Dental Care Vision Care Short Term Disability Long Term Disability Critical Illness InsuranceLife Insurance & AD&D are mandatory in a group plan

Preferred coverage option: (required)
 80% coverage for Dental 100% coverage for Dental 80% coverage for Health Benefits (ie. prescriptions, etc.) 100% coverage for Health Benefits (ie. prescriptions, etc.) with deductible without deductible

Are any Employees seasonal or part time?: (required)

Are eligible Employees participating in plan?: (required)

If no, please explain:

Are any Employees absent from work due to maternity, a disability or a certain leave?: (required)

If yes, please explain:

Are your Employees covered by WCB?: (required)

How many Employees are related by blood or marriage?: (required)

Other coverages you are interested in: (required)
 Buy / Sell Insurance (partnership) Key Person Insurance Health Spending Account Life Insurance Group Critial Illness Group Pension / RRSP's

Comments

Privacy Policy: (required)
 Yes, I agree to Integrity Insurance & Financial Services Inc. the use of our submitted information to obtain a quote for my/our Business or Practice.Integrity Insurance & Financial Services Inc. values your business and we thank you for your confidence in us to negotiate your Group Employee Benefits on your behalf. All information is held in strict confidence and only shared with the Insurance Companies that we are obtaining a quote from.

Employee Information: (required)
 Yes, I agree to complete the below Employee Data Sheet (or if your company form holds the same employee information as our data sheet, we will accept it). If a current group plan is in place, please attach PLAN DESIGN, RATE HISTORY AND CLAIMS EXPERIENCE. This can be completed and uploaded below with this eQuote. Thank you. You will be sent an authorization letter upon receipt of this eQuote.

File Upload
Upload your current PLAN DESIGN, EMPLOYEE INFORMATION, CLAIMS EXPERIENCE & RATE HISTORY.

If you have chosen a big file, it may take several minutes to upload. Please be patient. Hit the SUBMIT button only once, as hitting it a second time will cause serious delays in transmitting your file.

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Request_for_Quotation_Fillable.pdf 164.97 KB
Employee_Data_Sheet_20_Fillable.pdf 603.79 KB
Employee_Data_Sheet_20.pdf  122.6 KB
Employee_Data_Sheet_100.pdf  287.02 KB
Request_for_Quotation.pdf  125.04 KB