For a quote on coverage and more information on the plan, please fill out the following section. We will process your information and get back to you with a quote.
Employee #1
Name
Age
Income
Gender Male Female
Coverage Single Family
Smoker Yes No
Employee #2
Name
Age
Income
Gender Male Female
Coverage Single Family
Smoker Yes No

Coverage Selection (select only coverages you are interested in)
Long Term Disability
Critical Illness
Weekly Indemnity
Choose One:
      Extended Health 1: $250 deductible, 70% coverage OR
      Extended Health 2: $100 deductible, 80% coverage OR
      Extended Health 3: No deductible, 90% coverage
Choose One:
      Dental 1: 80% Basic OR
      Dental 2: 80% Basic, 50% Major (ie crowns, bridges), 50% orthodontics OR
      Dental 3: 100% Basic, 50% Major, 50% orthodontics

Eligibility Requirements:
• Under age 65
• Health questionnaire on you and all your eligible dependants