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:
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 Type:

Employee 31

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

Employee 32

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

Employee 33

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

Employee 34

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

Employee 35

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

Employee 36

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

Employee 37

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

Employee 38

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

Employee 39

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

Employee 40

Employee:
Occupation:
DOB or Age:
Approx date of hire:
Salary (if quoting disability):
Sex:
Coverage Type:

Employee 41

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

Employee 42

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

Employee 43

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

Employee 44

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

Employee 45

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

Employee 46

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

Employee 47

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

Employee 48

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

Employee 49

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

Employee 50

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