KBC

Fill and submit the information below and we will get a quote out to you promptly.

General Business Information:

Legal Company Name: (required)

Address:

City: Prov: Postal:

Tel: Fax:

From (email): (required)

Plan Administrator Name:

What is the Nature of Your business?

Benefit Needs: (Select the Benefits you require)

		Life Insurance			Disablity
		Medical Expenses			Dental
		Retirement

Benefit Selection:

Employee Life AD&D
Flat:		$25,000		$50,000
Salary:		1x		2x		3x

Dependant Life:		$5000 spouse / $2500 child				$10,000 spouse / $5,000 child

Weekly Income:		66.70%		other
Weekly Max:		$500		$750		$1000
Benefit Period:		17 Weeks		26 Weeks
		Non-Taxable		Taxable

LTD Benefit		60%		66.70%
		$2,500		$3,000		$3,500
		$4,000		$5,000
Elimination Period		119 days		181 days
		Non-Taxable		Taxable

Dental:

Basic		70%		80%		100%
Major		50%		60%
Maximum		$1,500 combined		$2,000 combined
Ortho		50%		$1500 lifetime		$2,000 lifetime

Extended Health Care:

Drugs		70%		80%		100%
		PayDirect		Reimbursement
All Other Services		80%		100%
Vision		$150		$200

Employee Data Sheet:

Name	Sex	D.O.B	Coverage	Occupation	Salary
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
	M		Single
	F		Family
			Waive
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