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Create the plan(s) you would ideally like for us to quote, containing a minimum of 3 benefits lines

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Build Your Own Plan

Create the plan(s) you would ideally like for us to quote, containing a minimum of 3 benefits lines

Step1

Step2

Step3

Step4

Producer Name:

Desired Effective Date:

Company Name:

Address:

City / Province / Postal Code

Mailing Address: (if different from above)

Telephone:

Fax:

Email:

Website:

Describe nature of business

Home Based?

Yes

No

Years in business

# of employees related to owner

Associated / subsidiaries covered:

Yes

No

All eligible employees participating:

Yes

No

Employee(s) absent due to disability:

Yes

No

Employees work min. 20 hours weekly:

Yes

No

Employees currently traveling outside Canada?

Yes

No

Seasonal Employees ( 9 month min):

Yes

No

Independent contractors:

Yes

No

Employees covered by WCB:

Yes

No

Please select

Please select
25%
30%
35%
40%
45%
50%
55%
60%
65%
70%
75%
80%
85%
90%
95%
100%

Employer Contribution (%)

Select the Priority of each below, ranking 1-7 with 1 being highest.

Please select

Please select
1
2
3
4
5
6
7

Life Insurance

Please select

Please select
1
2
3
4
5
6
7

Drugs

Please select

Please select
1
2
3
4
5
6
7

EHC

Please select

Please select
1
2
3
4
5
6
7

Vision

Please select

Please select
1
2
3
4
5
6
7

Dental

Please select

Please select
1
2
3
4
5
6
7

WI

Please select

Please select
1
2
3
4
5
6
7

LTD

Current Employee Benefit plan?

Yes

No

Current Insurance Carrier

Check all Current Benefits that apply:

Life

AD&D

Dep Life

Drugs

Visop

Vision

Dental

WI

LTD

# of carriers in the past 5 years

Reason for changes in Insurance Carrier

Please select

Please select
Broker approached
Renewal
Changing plan design
Price

Reason for requesting quote

Last billing statement attached:

Yes

No

To Follow

Copy of current Benefit booklet:

Yes

No

To Follow

Copy of most recent Renewal:

Yes

No

To Follow

Upload Statement

Upload

% Completed0

Upload Booklet

Upload

% Completed0

Upload Recent Renewal

Upload

% Completed0

Quote 1 / Class 1

Class 1

Select Quote 1 or Class 1
Quote 1
Class 1

75

65
70
71
75
80
85
Retirement

Termination Age

Select Amount

Select Amount
10,000
15,000
20,000
25,000
30,000
40,000
50,000
60,000
75,000
100,000
1X's Income
2X's Income
3X's Income
4X's Income
5X's Income

Life Insurance - Required Benefit

Select Benefit

Select Benefit
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000

Critical Illness

Select Amount

Select Amount
$5,000 / $2,500
$10,000 / $5,000
$15,000 / $7,500
$20,000 / $10,000

Dependant Life

Select Amount

Select Amount
$5,000 / $2,500
$5,000 / $2,500
$10,000 / $5,000
$15,000 / $7,500
$20,000 / $10,000

Dependant Critical Illness

Short Term Disability

Non-Taxable

Taxable

Select Benefit
50%
66.67%
70%
75%
80%

Short Term Disability %

Select Benefit Period

Select Benefit Period
15 Weeks
17 Weeks
26 Weeks

Select Waiting Period

Select Waiting Period
15 Weeks
17 Weeks
26 Weeks

Select STD Max. Benefit

Select STD Max. Benefit
EI Max
$500
$600
$700
$800
$900
$1000
$1,500

Long Term Disability

Non-Taxable

Taxable

Select Benefit

Select Benefit
50%
60%
65%
66.67%
70%
75%
80%
Graded Scale

Long Term Disability %

Select Benefit Period

Select Benefit Period
2 Years
5 Years
to age 65

Select Waiting Period

Select Waiting Period
112 days
119 days
181 days

Select LTD Max. Benefit

Select LTD Max. Benefit
$1,000
$1,500
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
EI Max

Select Cost of Living Adjustment

Select Cost of Living Adjustment
3%
4%
5%
CPI

Extended Health Care

Select Deductible

Select Deductible
25/25
25/50
50/100
100/200
250/500

Single/Family Deductible

Select Overall Maximum

Select Overall Maximum
Unlimited
$1,000,000
$2,000,000
$3,000,000
$5,000,000

Select Overall EHC Coverage

Select Overall EHC Coverage
100%
90%
80%
70%
60%
50%

Select Prescription Coverage

Select Prescription Coverage
100%
90%
80%
70%
60%
50%
100% / 80% (Generic / Brand)
90% / 70% (Generic / Brand)
80% / 60% (Generic / Brand)

Select Drug Plan

Select Drug Plan
Generic - Allowing for Substitutions
Mandatory generic equivalent only
Two Tier - Brand / Generic

Select Drug Maximum

Select Drug Maximum
$1,000
$1,500
$2,000
$3,000
$5,000
$10,000
$25,000
$50,000
$100,000
Unlimited

Paramedical Services

Basic

Basic & Supplementary

Select Paramedical Services Maximum

Select Paramedical Services Maximum
$100
$150
$200
$250
$300
$350
$500
$750
$1,000

Paramedical Services Max.

Vision Care

Select for Eye exams

Select for Eye exams
per 24 months
per 24 months Adult / 12 month child

Vision

Select Eye Exam Coverage

Select Eye Exam Coverage
R&C
$80
$60
$50
$150
$200
$250
$300
$350

Select for Frames / Lenses

Select for Frames / Lenses
$150
$200
$250
$300
$350

Hospital

Private

Semi-Private

Please select

Please select
Yes
No

Employee Assistance Program?

Please select

Please select
Yes
No

Second Opinion Consult?

Dental Care

Select Deductible

Select Deductible
25/25
25/50
50/100
100/200
250/500

Single/Family Deductible

Select Basic Coverage

Select Basic Coverage
100%
90%
80%
70%
60%
50%

Basic Dental (50 - 100%)

Select Major Coverage

Select Major Coverage
80%
70%
60%
50%

Major Dental (50 - 100%)

Select Lifetime Maximum

Select Lifetime Maximum
$1,000
$1,500
$2,000
$2,500
$3,000

Orthodontics (Groups of 7+ only)

Select Periods

Select Periods
1 / 6 Months
1 / 9 Months
1 / 12 Months

Recal Exams

Select Maximum Amount

Select Maximum Amount
-
$750
$1,000
$1,500
$2,000
$2,500
$3,000
$3,000

Dental Maximum Coverage

Quote 2 / Class 2

Select Quote 2 or Class 2

Select Quote 2 or Class 2
Quote 2
Class 2

75

65
70
71
75
80
85
Retirement

Termination Age

Select Amount

Select Amount
10,000
15,000
20,000
25,000
30,000
40,000
50,000
60,000
75,000
100,000
1X's Income
2X's Income
3X's Income
4X's Income
5X's Income

Life Insurance - Required Benefit

Select Benefit

Select Benefit
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000

Critical Illness

Select Amount

Select Amount
$5,000 / $2,500
$10,000 / $5,000
$15,000 / $7,500
$20,000 / $10,000

Dependant Life

Select Amount

Select Amount
$5,000 / $2,500
$5,000 / $2,500
$10,000 / $5,000
$15,000 / $7,500
$20,000 / $10,000

Dependant Critical Illness

Short Term Disability

Non-Taxable

Taxable

Select Benefit

Select Benefit
50%
66.67%
70%
75%
80%

Short Term Disability %

Select Benefit Period

Select Benefit Period
15 Weeks
17 Weeks
26 Weeks

Select Waiting Period

Select Waiting Period
15 Weeks
17 Weeks
26 Weeks

Select STD Max. Benefit

Select STD Max. Benefit
EI Max
$500
$600
$700
$800
$900
$1000
$1,500

Long Term Disability

Non-Taxable

Taxable

Select Benefit

Select Benefit
50%
60%
65%
66.67%
70%
75%
80%
Graded Scale

Long Term Disability %

Select Benefit Period

Select Benefit Period
2 Years
5 Years
to age 65

Select Waiting Period

Select Waiting Period
112 days
119 days
181 days

Select LTD Max. Benefit

Select LTD Max. Benefit
$1,000
$1,500
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
EI Max

Select Cost of Living Adjustment

Select Cost of Living Adjustment
3%
4%
5%
CPI

Extended Health Care

Select Deductible

Select Deductible
25/25
25/50
50/100
100/200
250/500

Single/Family Deductible

Select Overall Maximum

Select Overall Maximum
Unlimited
$1,000,000
$2,000,000
$3,000,000
$5,000,000

Select Overall EHC Coverage

Select Overall EHC Coverage
100%
90%
80%
70%
60%
50%

Select Prescription Coverage

Select Prescription Coverage
100%
90%
80%
70%
60%
50%
100% / 80% (Generic / Brand)
90% / 70% (Generic / Brand)
80% / 60% (Generic / Brand)

Select Drug Plan

Select Drug Plan
Generic - Allowing for Substitutions
Mandatory generic equivalent only
Two Tier - Brand / Generic

Select Drug Maximum

Select Drug Maximum
$1,000
$1,500
$2,000
$3,000
$5,000
$10,000
$25,000
$50,000
$100,000
Unlimited

Paramedical Services

Basic

Basic & Supplementary

Select Paramedical Services Maximum

Select Paramedical Services Maximum
$100
$150
$200
$250
$300
$350
$500
$750
$1,000

Paramedical Services Max.

Vision Care

Select for Eye exams

Select for Eye exams
per 24 months
per 24 months Adult / 12 month child

Select Eye Exam Coverage

Select Eye Exam Coverage
R&C
$80
$60
$50
$150
$200
$250
$300
$350

Select for Frames / Lenses

Select for Frames / Lenses
$150
$200
$250
$300
$350

Hospital

Private

Semi-Private

Please select

Please select
Yes
No

Employee Assistance Program?

Please select

Please select
Yes
No

Second Opinion Consult?

Dental Care

Select Deductible

Select Deductible
25/25
25/50
50/100
100/200
250/500

Single/Family Deductible

Select Basic Coverage

Select Basic Coverage
100%
90%
80%
70%
60%
50%

Basic Dental (50 - 100%)

Select Major Coverage

Select Major Coverage
80%
70%
60%
50%

Major Dental (50 - 100%)

Select Lifetime Maximum

Select Lifetime Maximum
$1,000
$1,500
$2,000
$2,500
$3,000

Orthodontics (Groups of 7+ only)

Select Periods

Select Periods
1 / 6 Months
1 / 9 Months
1 / 12 Months

Recal Exams

Select Maximum Amount

Select Maximum Amount
-
$750
$1,000
$1,500
$2,000
$2,500
$3,000
$3,000

Dental Maximum Coverage

Quote 3 / Class 3

Select Quote 3 or Class 3

Select Quote 3 or Class 3
Quote 3
Class 3

75

65
70
71
75
80
85
Retirement

Termination Age

Select Amount

Select Amount
10,000
15,000
20,000
25,000
30,000
40,000
50,000
60,000
75,000
100,000
1X's Income
2X's Income
3X's Income
4X's Income
5X's Income

Life Insurance - Required Benefit

Select Amount

Select Amount
$5,000 / $2,500
$10,000 / $5,000
$15,000 / $7,500
$20,000 / $10,000

Dependant Life

Select Benefit

Select Benefit
$5,000
$10,000
$15,000
$20,000
$25,000
$30,000
$35,000
$40,000
$45,000
$50,000
$55,000
$60,000
$65,000
$70,000
$75,000
$80,000
$85,000
$90,000
$95,000
$100,000

Critical Illness

Select Amount

Select Amount
$5,000 / $2,500
$5,000 / $2,500
$10,000 / $5,000
$15,000 / $7,500
$20,000 / $10,000

Dependant Critical Illness

Short Term Disability

Non-Taxable

Taxable

Select Benefit

Select Benefit
50%
66.67%
70%
75%
80%

Short Term Disability %

Select Benefit Period

Select Benefit Period
15 Weeks
17 Weeks
26 Weeks

Select Waiting Period

Select Waiting Period
15 Weeks
17 Weeks
26 Weeks

Select STD Max. Benefit

Select STD Max. Benefit
EI Max
$500
$600
$700
$800
$900
$1000
$1,500

Long Term Disability

Non-Taxable

Taxable

Select Benefit

Select Benefit
50%
60%
65%
66.67%
70%
75%
80%
Graded Scale

Long Term Disability %

Select Benefit Period

Select Benefit Period
2 Years
5 Years
to age 65

Select Waiting Period

Select Waiting Period
112 days
119 days
181 days

Select LTD Max. Benefit

Select LTD Max. Benefit
$1,000
$1,500
$2,000
$3,000
$4,000
$5,000
$6,000
$7,000
$8,000
$9,000
$10,000
EI Max

Select Cost of Living Adjustment

Select Cost of Living Adjustment
3%
4%
5%
CPI

Extended Health Care

Select Deductible

Select Deductible
25/25
25/50
50/100
100/200
250/500

Single/Family Deductible*

Select Overall Maximum

Select Overall Maximum
Unlimited
$1,000,000
$2,000,000
$3,000,000
$5,000,000

Select Overall EHC Coverage

Select Overall EHC Coverage
100%
90%
80%
70%
60%
50%

Select Prescription Coverage

Select Prescription Coverage
100%
90%
80%
70%
60%
50%
100% / 80% (Generic / Brand)
90% / 70% (Generic / Brand)
80% / 60% (Generic / Brand)

Select Drug Plan

Select Drug Plan
Generic - Allowing for Substitutions
Mandatory generic equivalent only
Two Tier - Brand / Generic

Select Drug Maximum

Select Drug Maximum
$1,000
$1,500
$2,000
$3,000
$5,000
$10,000
$25,000
$50,000
$100,000
Unlimited

Paramedical Services

Basic

Basic & Supplementary

Select Paramedical Services Maximum

Select Paramedical Services Maximum
$100
$150
$200
$250
$300
$350
$500
$750
$1,000

Paramedical Services Max.

Vision Care

Select for Eye exams

Select for Eye exams
per 24 months
per 24 months Adult / 12 month child

Select Eye Exam Coverage

Select Eye Exam Coverage
R&C
$80
$60
$50
$150
$200
$250
$300
$350

Select for Frames / Lenses

Select for Frames / Lenses
$150
$200
$250
$300
$350

Hospital

Private

Semi-Private

Please select

Please select
Yes
No

Employee Assistance Program?

Please select

Please select
Yes
No

Second Opinion Consult?

Dental Care

Select Deductible

Select Deductible
25/25
25/50
50/100
100/200
250/500

Single/Family Deductible

Select Basic Coverage

Select Basic Coverage
100%
90%
80%
70%
60%
50%

Basic Dental (50 - 100%)

Select Major Coverage

Select Major Coverage
80%
70%
60%
50%

Major Dental (50 - 100%)

Select Lifetime Maximum

Select Lifetime Maximum
$1,000
$1,500
$2,000
$2,500
$3,000

Orthodontics (Groups of 7+ only)

Select Periods

Select Periods
1 / 6 Months
1 / 9 Months
1 / 12 Months

Recal Exams

Select Maximum Amount

Select Maximum Amount
-
$750
$1,000
$1,500
$2,000
$2,500
$3,000
$3,000

Dental Maximum Coverage

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