Prairie Wide Group

Group Benefits Quote Request

Tell us a bit about your business so we can prepare a benefits quote that fits your team, your budget, and your long-term goals. Approximate information is okay at this stage. Everything submitted is kept confidential and used only for quoting purposes.
Company Name:
Company Mailing Address:

Street Address

Street Address Line 2

CityProvince

Postal Code
Company Phone:

Area CodePhone Number
Company Contact Name:
Contact Email Address:
example@example.com
Preferred Contact Method:
Phone | Email | Text Message
Do you currently have a group benefits plan in place?
Current provider:
Renewal date for current provider:

MonthDayYear
Date
Have you changed benefits providers in the last 3 years?
Previous benefits provider?
Approximate number of years with previous provider?
Are any employees presently not actively at work due to a disability?
Does your company currently have active WCB coverage?
What would you like us to focus on when preparing your quote? (Select all that apply)
Please provide any extra details we may find helpful while quoting:
Employee Census Information

Please include all eligible employees. Initials are fine at this stage. If you already have a census spreadsheet, you can upload it instead.

Rows	Employee Name or Initials	Sex	Coverage Type	Occupation	Date of Birth or Age	Annual Earnings (only required if quoting disability coverage	Hire Date
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Group Benefits Quote Request