Prairie Wide Services

Company Name

Primary Contact

Type of Business

How many years in business.

Are all employees/contractors covered by WCB?

YES
NO

Address

Address

Country	Province/State

City	Postal/Zip Code

Phone Number

- -

Email

Do all employees work more than 20 hours a week?

Yes
No

At the present time, are any employees absent from work due to disability, maternity leave, or other leave of absences?

Yes
No

If yes, explain.

If you have employee info already compiled, please attach here. ie employee census, billing Statements, current renewal etc:

What percentage of employees are related

Comments & additional info

If you have employee info already compiled, please attach here. ie employee census, billing Statements, current renewal etc:

Attach Here:

If you have attached info above, then please disregard questions below. go directly to bottom and submit.

Employee 1

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage Type

Employee 2

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage Type

Employee 3

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Single
Family
Waive

Coverage

Employee 4

Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 5

Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 6

Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 7

Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 8

8. Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 9

Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 10

Employee Name

Occupation

DOB or Age

Approx Date of Hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 11

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 12

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 13

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 14

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 15

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
other

Coverage

Employee 16

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 17

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 18

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 19

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 20

20. Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 21

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 22

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 23

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 24

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 25

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 26

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 27

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 28

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 29

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 30

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 31

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 32

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 33

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 34

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 35

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Coverage

Sex

Male
Female
Other

Employee 36

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 37

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 38

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 39

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 40

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 41

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 42

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 43

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 44

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 45

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 46

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 47

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 48

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage

Employee 49

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Waive

Coverage

Employee 50

Employee Name

Occupation

DOB or Age

Approx date of hire

Salary (if quoting disability)

Sex

Male
Female
Other

Coverage