Green Mountain Financial Services Inc.
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905-921-9962
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Quick Benefits Quote
Quick Benefits Quote Form
G
REEN MOUNTAIN FINANCIAL
SERVICES INC.
Get a Free Group Benefits Quote
1.
Company Details
:
Company Name:
*
Contact Person:
*
Address:
*
City:
*
Province:
*
Postal:
*
Phone:
*
Email:
*
Website:
Type of Business:
Number of years in Operation: :
DO YOU CURRENTLY HAVE BENEFITS PLAN IN PLACE?
YES
NO
2.
N
umber of Employees:
Total:
Full Time:
Part Time:
3.
Current or Previous Coverage
(if
applicable)
:
Do you currently have a Group Benefits Plan?
YES
NO
If Yes, who is your current provider?
Renewal Date of Current Plan:
How long have you had this plan?
4. Benefits You
Are Interested In
Please check all that apply
Health Coverage (e.g. , prescription drugs, paramedical services)
Dental Coverage (e.g., preventative, restorative, orthodontics)
Vision Care
Life Insurance
Short-Term Disability
Long-Term Disability
Critical Illness Insurance
Employee Assistance Program (EAP)
Wellness Initiatives
Retirement Savings Plans (Group RRSPs, DPSPs, Pensions)
Other (please specify):
5. Plan Detail
Health:
Drugs:
Drug Cap:
Deductible:
Dental:
Major Dental:
Deductible:
Recall:
6 months
9 months
1 year
Orthodontics:
Dental Maximum:
Others (please specify):
Waiting Period for New Employees:
None
3 Months
6 Months
Others
Others (please specify):
Budget (Optional):
6. Additional Information
Please share any specific needs, concerns, or goals for your Group Benefits Plan:
Full Name
DOB
CLASS
GENDER
MALE
FEMALE
COVERAGE
SINGLE
FAMILY
JOB TITLE & SALARY(for disability quote)
plus1
minus1
Full Name
DOB
CLASS
GENDER
MALE
FEMALE
COVERAGE
SINGLE
FAMILY
JOB TITLE & SALARY(for disability quote)
plus1
minus1
Full Name
DOB
CLASS
GENDER
MALE
FEMALE
COVERAGE
SINGLE
FAMILY
JOB TITLE & SALARY(for disability quote)
plus1
minus1
Full Name
DOB
CLASS
GENDER
MALE
FEMALE
COVERAGE
SINGLE
FAMILY
JOB TITLE & SALARY(for disability quote)
plus1
minus1
Full Name
DOB
CLASS
GENDER
MALE
FEMALE
COVERAGE
SINGLE
FAMILY
JOB TITLE & SALARY(for disability quote)
plus1
minus1
Submit
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