Client Information

Client Questions

Are there any Seasonal or Contract Employees?

Yes

No

If yes, please specify:

Are 50% or more of the employees from the same family?

Yes

No

If yes, please indicate relationship and if they reside in the same household:

Premium contribution basis in Percentage:

Employer Pays

Employee Pays

(The employer is required to pay a minimum of 50%)

Are all employees and owners covered by Workers Compensation (WSIB)?

Yes

No

Are there any disabled employees?

Yes

No

If Yes, please complete the following chart in full (the notes area at the end may also be used):

	Employee Name	Occupation	Date of Disability	Nature of Disability	Prognosis	Life Waiver Approved?
Employee 1:
Employee 2:
Employee 3:

Are you currently insured?

Yes

No

If yes, please indicate the following:

Current Carrier

Number of Years With Carrier

Renewal Date

Are benefits being quoted the same as your current plan?

Yes

No

If not, explain why:

Experience and rates provided? (Please include the most current month and a minimum of two years (preferably three))

Yes

No