Group Benefits  30 - 50 Employees

Company Name:
Primary Contact:
Type of Business:
How many years in business?
Are all employees covered by WCB?
What do you like about your current provider/ Benefits program?
What do you not like about your current provider/ Benefits program?
Attach a copy of your most recent renewal.
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?
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:
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

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 Namehttps:
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):
Sex:
Coverage:

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:
Salary (if quoting disability):
Sex:
Coverage: