REQUEST A QUOTE

For 10 or less employees you may use this form to obtain a quote.

For 11 or more employees please use the print version of this form and fax to (905)640-9535.

 

Company Information
Company Name:
Postal Code:
Contact Person:
Telephone:
Fax:
Email:
Employee Benefit Data
Employee 1
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 2
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 3
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 4
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 5
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 6
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 7
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 8
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 9
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
 
Employee 10
Name:
Age:
Sex:
Salary: monthly annual

Occupation:
Workman's Comp:
Type Of Coverage:
   
 
 

 

BENEFITS MANAGEMENT GROUP INC. | 200 Dougherty Crescent | Stouffville, Ontario L4A 0A6
Telephone: 905.640.1344 | Toll-Free: 1.866.540.1344 | Fax: 905.640.9535 | Email: info@benefitsmgmt.ca