Group Products

Employee Survey

First Name * :
Last Name * :
Email * :
Company's Full Legal Name * :
Address 1:
Address 2:
City:
Province:
Postal Code:
Phone * :
Alternate Phone:
Fax:
Name of Controller or HR Manager: Title:
Name of Plan Administrator: Title:
Nature of Business:
Years in operation:
Number of Full-time employees
(min 25hr per week):
Full-time employees last year:
Employees related to owner:
Are any employees not actively at work due to accident or sickness? Yes No
Do you currently have a benefit program? Yes No
Current Insurance Company:


Benefit Plan Selection

Plan Design
Description
Select One
Life, Accidental Death and Dismemberment (AD&D)
1
  • Flat $25,000
2
  • 1 x salary
None None
 
Dependant Life
1
  • $5,000 Spouse $2,500 for each dependent child
2
  • $10,000 Spouse $5,000 for each dependent child
None None
 
Extended Health
1
  • Unlimited overall maximum
  • Semi-Private Hospital
  • Drug Card Plan: 80%
  • Chiropractor, massage service etc.: 80% to $500 per practitioner
  • Out of Country coverage
2
  • Unlimited overall maximum
  • Semi-Private Hospital
  • Drug Card Plan: 100%
  • Chiropractor, massage service etc.: 100% to $500 per practitioner
  • Out of Country coverage
None None
 
Dental Care Coverage
1
  • Maximum $1,000/year
  • Basic dental including cleaning, x-rays, root canal etc. @ 80%
  • 2 visits per calendar year
2
  • Maximum $1,000/year
  • Basic dental including cleaning, x-rays, root canal etc. @ 100%
  • 2 visits per calendar year
None None
 
Short Term Disability coverage optional
1
  • Non-taxable: 66.7% of weekly earnings
  • Maximum: $500 / week
  • Elimination Period: 0 / 7
  • Benefit Period: 17 weeks
2
  • Non-taxable: 66.7% of weekly earnings
  • Maximum: $1,000 / week
  • Elimination Period: 0 / 7
  • Benefit Period: 17 weeks
None None
 
Long Term Disability coverage optional
1
  • Non-taxable: 66.7% of weekly earnings
  • Benefit Maximum: $2,000 / month
  • Disability Definition: 2-year own occupation
  • Benefits payable up to age 65
2
  • Non-taxable: 66.7% of weekly earnings
  • Benefit Maximum: $3,000 / month
  • Disability Definition: 2-year own occupation
  • Benefits payable up to age 65
None None