Company Name:* Contact Name: Last name* First name* Middle Initial Address: Street* Suite/Unit City* Province* Postal Code* Phone:* Email:* Are all employees actively at work?YesNo If yes, please provide details: Are any employees on disability?YesNo If yes, please provide details Are there commissioned workers?YesNo If yes, please provide details Are any employees seasonal?YesNo If yes, please provide details Are any employees contractors?YesNo If yes, please provide details * Additional information may be required to determine eligibility Length of time in business Total # of employees Nature of Business Additional notes Does the client currently have benefits?YesNo If you answered Yes to the above question, the following information is MANDATORY to provide an experience rated quote: 1. Claims Experience Summary (i.e. current carrier’s most recent renewal report, and/or up to date claims experience from the past year, or 2 years if available). 2. Current Premiums/Rate History (i.e. rate summary from most recent renewal report). 3. Current Benefit Plan Design (i.e. summary of benefits from the employee booklet(s)). NOTE: THE ABOVE REQUIREMENTS ARE ESSENTIAL AND A QUOTATION CANNOT BE ISSUED WITHOUT IT
