REQUEST FOR PROPOSAL


Please fill in the following form for a complete proposal or click here for a PDF you can print out and either fax or mail into our offices. Please note that * denotes a required field.

Part 1 – General Information

*Company Name:

*Incorporated:

Yes No

*Address:

 

 

City:

 

*Province:

*Postal Code:

 

*Telephone:

 

Fax Number:

 

*Contact Name:

 

Title:

 

*Email Address:

 


Part 2 – Group Coverage Information General Information

Do you presently have a Dental or Healthcare benefit plan?
(if yes, please complete section 4)

Yes No

Number of employees that will be plan members:

Number of dependents (spouse and/or dependent children) that will be plan members:



Part 3 – Details of Proposal Request

Please choose which services are to be covered:

Dental

Extended Healthcare (EHC)

Vision

Prescription Drugs

Are you interested in Out-Of-Province/Canada Travel Medical Emergency and Catastrophic Stop Loss Insurance coverage for your employees?

Yes No

Do you want your plan to include employee co-payments? For example, for a 20% co-payment plan, the plan would cover 80% of expenses and employees would be responsible for the remaining 20%. Please specify co-payment options, if applicable, in the table below:

The annual dollar maximum benefit is based on per covered employee and eligible dependent.

Class

# of Employee(s)

Annual Maximum

Co-Payment %

E.g. Executive Family

4

$3,000

0%



Part 4 – Current Coverage Information

Please provide us with details of your existing plan, if applicable, as well as any proposed changes. You can fill in this form or provide us with a copy of your renewal information. Please provide at least 3 years of experience, or as long as the plan has been in place.

 

Current Plan

Proposed

Dental

 

 

 

Deductible

 

 

 

Basic%

 

 

 

Major%

 

 

Orthodontics%

 

 

 

Annual Maximum

 

 

Extended Healthcare(EHC)/Drug

 

 

 

Deductible

 

 

 

Co-insurance%

 

Annual Maximums

 

Drug Exclusions
(e.g. fertility drugs)

 

 

Vision ($/frequency)

 

 

Out-of-Province/Canada Travel Medical Emergency Insurance

 

 

 

 

Please record your previous premium and claims history.

Coverage

Projected

Last Year

Two Years Ago

  

Premium

Claims

Premium

Claims

Premium

Claims

Dental

Extended Healthcare (EHC)/Drug



Part 5 – Broker / Advisor Information

Name:

Address:

 

 

 

Telephone:

Fax Number:

Mobile Number:

Email Address:

 

  

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