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Customize a Benefits Plan
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Step
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Name
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First
Last
Email
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Phone
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Province/Territory
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Newfoundland
Nova Scotia
New Brunswick
Prince Edward Island
Quebec
Ontario
Manitoba
Saskatchewan
Alberta
British Columbia
Yukon
Northwest Territories
Nunavut
Preferred Language
English
Français
Plan Type
*
Individual
Couples
Single Parent
Family
Group
In the Last 90 days, Have You Been a Member of an Group Benefits Plans?
No
Yes
Legal Status of Entity
Person
Sole Proprietorship
Partnership
Corporation
Co-Operative
Association
Non-Profit
Entity Name
Website / URL
Do You Currently Have a Group Benefits Plan?
No
Yes
When is its Renewal Date?
Employee Census
Click or drag a file to this area to upload.
Benefits Booklets for All Classes
Click or drag a file to this area to upload.
Rate History Report (Last 3 Years)
Click or drag a file to this area to upload.
Claims & Premium Paid History Report (Last 3 Years)
Click or drag a file to this area to upload.
Number of Year in Operation
0 Years
1 Years
2 Years
3 Years
5 Years
10+ Years
Nature of Operations
Date of Birth
*
Is There Currently Anyone Taking Prescription Medication?
No
Yes
Are You Currently Taking Prescription Medication?
No
Yes
Details of Prescriptions
Gender
Female
Male
Other
Smoking Habits
Cannabis
Tobacco
Chewing Tobacco
Occupation
Annual Income
Date of Birth - Spouse
Gender - Spouse
Female
Male
Other
Smoking Habits - Spouse
Cannabis
Tobacco
Chewing Tobacco
Occupation - Spouse
Annual Income - Spouse
Number of Children
Number of Members
Number of Employees
Are All Employees Covered by Employment Insurance?
Yes
No
Percentage of Employees Not Covered by Employment Insurance
5%
10%
25%
50%
75%
100%
Are Any Employees Covered by Workers Compensation?
Yes
No
Percentage of Employees Covered by Workers Compensation
5%
10%
25%
50%
75%
100%
Percentage of Employees Related to Owner
None
10%
25%
50%
75%
100%
Number of Employees/Members 1 Year Ago
Percentage of Employee Turn-Over from 1 Year Ago
0%
5%
10%
25%
50%
75%
100%
Percentage of Seasonal Employees
None
10%
25%
50%
75%
100%
Are there any independent contractors seeking coverage?
No
Yes
What Percentage of the Workforce are Independant Contractors?
5%
10%
25%
50%
75%
100%
Are there Unions Involved?
No
Yes
Are There Commissioned Employees?
No
Yes
All Insured - Date of Birth, Gender, Occupation, Annual Income
Next
Life Insurance ($)
This pays out a lump sum tax-free benefit in the event of your passing
Life Insurance ($) - Spouse
Life Insurance ($) - Children
Disability Benefits (% of Income)
None
10%
25%
33%
40%
50%
60%
70%
Maximum
What percentage of your monthly income would you like to insure from disability?
Disability Benefit Period
1 Year
2 Years
5 Years
To Age 65
In the event of a disability, for how long would you like to receive benefits?
Disability Waiting Period
14 Days
30 Days
60 Days
90 Days
120 Days
In the event of a disability, how long can you wait before starting to receive benefits?
Disability Benefit (% of Income) - Spouse
What percentage of your spouse's monthly income would you like insure from disability?
Disability Benefit Period - Spouse
1 Year
2 Years
5 Years
To Age 65
In the event of a disability, for how long would your spouse like to receive benefits?
Disability Waiting Period - Spouse
14 Days
30 Days
60 Days
90 Days
120 Days
In the event of a disability, how long can your spouse wait before starting to receive benefits?
Critical Illness Coverage ($)
This pays out a lump sum tax-free benefit in the event that you get diagnosed with a life threatening condition
Critical Illness Coverage ($) - Spouse
Critical Illness Coverage ($) - Children
Accidental Death & Dismemberment ($)
This pays out a lump sum tax-free benefit in the event that you die accidentally or if you lose a limb
Accidental Fracture
None
$5,000
$10,000
This benefit provides for a lump sum payment in the event of a fracture suffered
Accidental Death & Dismemberment ($) - Spouse
This pays out a lump sum tax-free benefit in the event that you die accidentally or if you lose a limb
Accidental Fracture - Spouse
None
$5,000
$10,000
This benefit provides for a lump sum payment in the event of a fracture suffered
Accidental Death & Dismemberment ($) - Children
This pays out a lump sum tax-free benefit in the event that you die accidentally or if you lose a limb
Accidental Fracture - Children
None
$5,000
$10,000
This benefit provides for a lump sum payment in the event of a fracture suffered
Accidental Loss of Use ($)
This benefit provides compensation in cases of accidental loss of hearing, sight, speech or use of limbs.
Accidental Loss of Use ($) - Spouse
This benefit provides compensation in cases of accidental loss of hearing, sight, speech or use of limbs.
Accidental Loss of Use ($) - Children
This benefit provides compensation in cases of accidental loss of hearing, sight, speech or use of limbs.
Dental Benefits
None
Basic
Enhanced
This benefit provides reimbursement for ongoing and unexpected cost relating to oral care
Prescription Benefits
None
Basic
Enhanced
This benefit provides reimbursement for ongoing and unexpected prescription costs
Vision Care Benefits
None
Basic
Enhanced
This benefit provides reimbursement and discounts for ongoing and unexpected vision care related expenses
Emergency Travel Health Insurance
None
Trips of 15 Days or Less
Trips of 30 Days or Less
Trips of 30+ Days
Covers unexpected costs in the event of health emergencies when outside your province of origin
Hospital Allowance ($)
None
$25
$50
$75
$100
This is a daily allowance if you become hospitalized
Hospital Allowance ($) - Spouse
None
$25
$50
$75
$100
This is a daily allowance if your spouse becomes hospitalized
Post Accident Adaption
Yes
No
This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident
Post Accident Adaption
None
Individual Only
Spousal
This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident
Post Accident Adaption
None
Individual Only
Entire Family
This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident
Post Accident Adaption
None
Individual Only
Couple Only
Entire Family
This benefit covers the services of an occupational therapist as well as the cost of residential adaption in the event of an accident
Medical Expenses Due to Accident
Yes
No
This benefit provides reimbursement for medical expenses in the event of an accident
Medical Expenses Due to Accident
None
Individual Only
Spousal
This benefit provides reimbursement for medical expenses in the event of an accident
Medical Expenses Due to Accident
None
Individual Only
Entire Family
This benefit provides reimbursement for medical expenses in the event of an accident
Medical Expenses Due to Accident
None
Individual Only
Couple Only
Entire Family
This benefit provides reimbursement for medical expenses in the event of an accident
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