Group Benefits 50 +Employees

Company Name
Primary Contact
Type of Business
How many years in business.
Are all employees/contractors covered by WCB?
Address
Address
Country Province/State
City Postal/Zip Code
Phone Number
- -
Email
Do all employees work more than 20 hours a week?
At the present time, are any employees absent from work due to disability, maternity leave, or other leave of absences?
If yes, explain.
What percentage of employees are related
Comments & additional info

Please attach below Client Census( employee name, occupation, DOB, DOH, sex, salary, coverage) along with any current billing info, renewal statement, etc.

Attach Here: