Email Address:
Company Name:
Contact Name:
Address:
City:
Province
Postal Code
Phone Number:
Fax Number (if applicable):
Describe the nature of your business:
Number of employees:
Do you have an existing group benefit plan? YesNo
Please check the type of coverage you are interested in: Extended Health Care (includes prescription drug coverage)Dental CareDependent's Life InsuranceShort Term DisabilityLong Term DisabilityCritical IllnessBusiness Overhead Expense
