New! eQuote Form for Group Benefits

Name of Business: *

Operating Business Name

Number of years in business: *

Number of years your company has been in business.

What is the nature of your Business?: *

What type of Industry does your Business focus on?

Number of Owners: *

How many Owners in your Business?

Has your Business ever had an Employee Benefits Plan?: *

Yes

If yes, which Insurance Company?:

Renewal Date:

Date your Benefits plan expires or renews.

Date when coverage is needed:

When new benefit plan is required to be in place.

First & Last name: *

Job Title:

Business Address: *

City: *

Province: *

Postal code: *

Phone: *

Fax:

Email: *

Website:

Number of Full time Employees: *

24+ hours worked per week

Benefits you are most interested in: *

Life Insurance & AD&D are mandatory in a group plan

Preferred coverage option: *

80% coverage for Dental

100% coverage for Dental

80% coverage for Health Benefits (ie. prescriptions, etc.)

100% coverage for Health Benefits (ie. prescriptions, etc.)

with deductible

without deductible

Are any Employees seasonal or part time?: *

Yes

Are eligible Employees participating in plan?: *

Yes

If no, please explain:

Are any Employees absent from work due to maternity, a disability or a certain leave?: *

Yes

If yes, please explain:

Are your Employees covered by WCB?: *

Yes

Other coverages you are interested in:

Comments:

Our Privacy Policy: *

Yes, I agree to Integrity Insurance & Financial Services Inc. the use of our submitted information to obtain a quote for my/our Business or Practice.

Integrity Insurance & Financial Services Inc. values your business and we thank you for your confidence in us to negotiate your Group Employee Benefits on your behalf. All information is held in strict confidence and only shared with the Insurance Companies that we are obtaining a quote from.

Employee Information: *

Yes, I agree to complete the below Employee Data Sheet (or if your company form holds the same employee information as our data sheet, we will accept it). If a current group plan is in place, please attach PLAN DESIGN, RATE HISTORY AND CLAIMS EXPERIENCE. This can be completed and uploaded below with this eQuote. Thank you. You will be sent an authorization letter upon receipt of this eQuote.

File Upload:

Upload PLAN DESIGN, EMPLOYEE INFORMATION, CLAIMS EXPERIENCE & RATE HISTORY. If you have chosen a big file, it may take several minutes to upload. Please be patient. Hit the SUBMIT button only once, as hitting it a second time will cause serious delays in transmitting your file.

CAPTCHA

This question is for testing whether you are a human visitor and to prevent automated spam submissions.

Math question: * 5 + 4 =

Solve this simple math problem and enter the result. E.g. for 1+3, enter 4.

Attachment	Size
Employee_Data_Sheet_20.pdf	122.6 KB
Employee_Data_Sheet_100.pdf	287.02 KB
Request_for_Quotation.pdf	125.04 KB

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