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Group Benefits Quote Request
Ontario's Leading Benefits Brokerage
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1
What is your First name?
*
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First Name
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2
What is your Last name?
*
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Last Name
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3
What is the name of your business?
*
This field is required.
Click "Next" if not applicable
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4
In which city are you located?
*
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5
How long have you been in business?
*
This field is required.
I'm just getting started
Less than a year
1 to 3 years
More than 3 years
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6
Do you currently have a group benefits plan in place?
*
This field is required.
YES
NO
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7
Approximately how many employees would this plan cover?
*
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8
Please provide the following data for up to 3 employees (if applicable). If you aren't sure, please leave blank.
Gender
Age (approx.)
Coverage Status
Employee 1
F
M
X
F
M
X
Row 0, Column 0
Row 0, Column 1
Single
Family
Single
Family
Row 0, Column 2
Employee 2
F
M
X
F
M
X
Row 1, Column 0
Row 1, Column 1
Single
Family
Single
Family
Row 1, Column 2
Employee 3
F
M
X
F
M
X
Row 2, Column 0
Row 2, Column 1
Single
Family
Single
Family
Row 2, Column 2
Employee 1
Employee 2
Employee 3
Gender
F
M
X
F
M
X
Row 0, Column 0
Age (approx.)
Row 0, Column 1
Coverage Status
Single
Family
Single
Family
Row 0, Column 2
Gender
F
M
X
F
M
X
Row 1, Column 0
Age (approx.)
Row 1, Column 1
Coverage Status
Single
Family
Single
Family
Row 1, Column 2
Gender
F
M
X
F
M
X
Row 2, Column 0
Age (approx.)
Row 2, Column 1
Coverage Status
Single
Family
Single
Family
Row 2, Column 2
1
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9
Would you also be interested in a commercial insurance quote for your business?
*
This field is required.
YES
NO
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10
Please briefly describe your business operation
*
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11
What is the best number to reach you?
*
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Area Code
Phone Number
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12
What is your email address?
*
This field is required.
example@example.com
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13
What can we do to be your Group Benefits Hero?
Anything else you would like to share?
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