Group Benefits 10 - 30 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:
At the present time, are any employees absent from work due to disability, maternity leave, or other leave of absences?
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 statement, 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 Type:

Employee 4

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

Employee 5

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

Employee 6

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

Employee 7

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

Employee 8

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

Employee 9

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

Employee 10

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

Employee 11

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

Employee 12

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

Employee 13

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

Employee 14

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

Employee 15

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

Employee 16

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

Employee 17

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

Employee 18

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

Employee 19

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

Employee 20

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

Employee 21

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

Employee 22

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

Employee 23

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

Employee 24

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

Employee 25

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

Employee 26

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

Employee 27

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

Employee 28

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

Employee 29

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

Employee 30

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