Free Group Benefits Quote

We will not be able to prepare a quote for your firm if some of the required information is missing. The quotation process will be halted until all pertinent information is received. If some of the required information is not available, please let us know. Thank-you.

1.  Please fill in the Online Request For Quotation form BELOW and submit it to our offices; OR

2.  You may also download this Request For Quotation form and fax or mail it into our offices. 

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 Print quote forms and mail or fax them to us - Request For Quotation Forms
(file size - 130 KB)
Submit Employee Benefit Data

GROUP INSURANCE QUOTE REQUEST - GET A QUOTE OVER THE INTERNET

* indicates required field

  
GENERAL INFORMATION:
Company Name:
Contact Name:
Address:
City:
Postal Code:
Phone No:
Fax No:
E-Mail:
 *
Date Submitted:
Date Required:


COMPANY INFORMATION:
1. Nature of Business?
2. Length of time in business?
3. Number of full-time employees (over 20 hours per week)?
4. Has no. of employees changed significantly over the past year? YES NO
5. Are all employees included in this data? (If no please provide details) YES NO
details for question #5:
6. How many employees are related to the owners/partners?
7. Are all workers covered by WCB? (If no please provide details) YES NO
details for question #7:
8. Are all workers covered by UIC? (If no please provide details) YES NO
details for question #8:
9. Is the employer contributing 50% towards the cost of the plan? YES NO
10. Is anyone disabled at present? (If yes please provide details below) YES NO
details for question #10:
11. Are there commissioned salespeople? YES NO
12. If yes to #11, what percentage of income is commission?
13. Current Insurer?
14. Current Provider Group No.?
15. Effective Date?
16. What is the primary reason for requesting a quotation?


INFORMATION REQUIRED TO PREPARE CUSTOM MADE PLAN
Employee's
Full Name
Start
Date
Occupation
Sex
Marital
Status
Dependent
Coverage
DOB
Annual
Earnings
Prov. of
Residence
1.
yes no
2.
yes no
3.
yes no
4.
yes no
5.
yes no
6.
yes no
7.
yes no
8.
yes no
9.
yes no
10.
yes no
11.
yes no
12.
yes no
13.
yes no
14.
yes no
15.
yes no
16.
yes no
17.
yes no
18.
yes no
19.
yes no
20.
yes no


COMMENTS, QUESTIONS OR OTHER DETAILS
Please provide any additional information that you may think is necessary.
By submitting this form, I/WE CERTIFY THAT all of the answers above are correct and complete. We hereby appoint Vic Perlinger of Perlinger Financial Services to act as the representative and Agent of Record to obtain quotations for our company’s employee group benefit program.

Vic Perlinger will serve as the Agent of Record for all quotations received from all insurers submitting such quotations. Please provide Perlinger Financial Services Ltd. with all the necessary information they are requesting and forward any questions you may have to them.



 


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