Group Benefits  30 - 50 Employees

Company Name
Primary Contact
Type of Business
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.

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

What percentage of employees are related

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
Coverage Type

Employee 2

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage Type

Employee 3

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 4

Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 5

Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 6

Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 7

Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 8

8. Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 9

Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 10

Employee Name
Occupation
DOB or Age
Approx Date of Hire
Salary (if quoting disability)
Sex
Coverage

Employee 11

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 12

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 13

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 14

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 15

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 16

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 17

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 18

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 19

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 20

20. Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 21

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 22

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 23

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 24

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 25

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 26

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 27

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 28

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 29

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 30

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 31

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 32

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 33

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 34

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 35

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Coverage
Sex

Employee 36

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 37

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 38

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 39

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 40

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 41

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 42

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 43

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 44

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 45

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 46

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 47

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 48

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 49

Employee Name
Occupation
DOB or Age
Approx date of hire
Salary (if quoting disability)
Sex
Coverage

Employee 50

Employee Name
Occupation
DOB or Age
Approx date of hire
Date of Birth
/ /
Date of Hire
/ /
Salary (if quoting disability)
Sex
Coverage