INGLE Insurance - Employer Group Health Benefits

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Employer Group Health Benefits


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Employer Group Health Benefits

Fill in the simple form below to request a quote on employee health insurance from Ingle Insurance.

Application Form

Applicant Information
First Name:
Last Name:
E-mail Address:
Address:
City:
Province:
Postal:
Phone:
Gender:
Date Of Birth:
Company Information
Company Name
Address
City:
Province:
Postal:
Years in business
Nature of business
Do all employees work a minimum of 20 hours per week?
	Yes No
Any employees on commission basis? (Details)

Employee covered by Workers Compensation?
	Yes No
Any employees involved in hazardous activities such as flying, offshore activities, handling of dangerous chemicals etc.?
	Yes No
Has there been a staff turnover more than 30% in the last two years?
	Yes No
Are all employees resident of Canada?
	Yes No
Do you have a present group plan?
	Yes No
If yes, with whom and for how long?

If yes, have any of your employees been declined for group coverage?
	Yes No
If yes, have any of your employees had any Life or Disability claims in the last 12 months?
	Yes No
Any employees presently off due to illness?
	Yes No
If yes, please give dates of birth, duration of absence and nature of illness/injury

If yes, are any of them receiving CPP/QPP, WSIB or any other disability benefits?
	Yes No
Any employees currently on Life or Disability Waiver of Premium?
	Yes No
Outline of current plan design including co-insurance and deductibles (if applicable).

Employee Information
Employee Name
Sex
Date of Birth
Marital Status
Date Employed
Province of Res.
Annual Earnings
Occupation

Click here to add an additional name to this form

Disclaimer

The information on this website does not constitute your official policy documents. All information on this website is provided for reference only. Policy wording, definitions, translations, product details coverage limits and plan details are subject to change at any time, without notice prior to a purchase and delivery of the policy.

The purchase of a policy confirms acceptance of the policy wording, terms, conditions, limits and exclusions set out therein. Ingle International and its affiliates are not responsible for differences between the information found on this site and the actual coverage provided.

If you have any questions about your coverage, please contact us at 1.877.294.6453 or helpline@inglememberbenefits.com

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