Valley Wide

Company Name:

Primary Contact:

Type of Business:

How many years in business?

Are all employees covered by WCB?

YES
NO

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:

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

Yes
No

If yes, please explain:

What percentage of employees are related?

Comments & additional info:

Please attach below Client Census( employee name, occupation, DOB, DOH, sex, salary, coverage) along with any current billing info, renewal notices etc.

Attach here: