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

 

Employee Benefit Data
Please return by mail or fax to (905)640-9535.

Company Name:_________________________Address:____________________________________Postal Code:__________(essential)

Contact Person:_________________________Phone:__________________Fax:________________

 

#
 Name Age Sex

(Male or Female)		 Salary

(Monthly or Annual Income)		 Occupation

(i.e. Office, Admin, Sales, Skilled Labour)		 Workman's Comp

(Yes or No)		 Type of Coverage

W = Waive Health & Dental covered through spouse
F = Family Coverage
S = Single Coverage
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