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
Extended Health Choose One:
      Bronze: $250 deductible, 70% coverage OR
      Silver: $100 deductible, 80% coverage OR
      Gold: No deductible, 90% coverage
Dental Choose One:
      Bronze: 80% Basic OR
      Silver: 80% Basic, 50% Major (ie crowns, bridges), 50% orthodontics OR
      Gold: 100% Basic, 50% Major, 50% orthodontics

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