Quotation

Life lnsurance and AD&D

Flat Benefit $ or (x) annual to max $

Dependent Life

$5,000/$2,500 $10,000/$5,000 Other $

Short Term Disability (optional)

I would like Short Term Disability coverage No Yes

Benefit Amount % to a maximum of $ / week

Plan Design 1-8-17 1-8-26 15-15-15 15-15-26

First day hospital No Yes

Taxable No Yes

Long Term Disability (optional)

I would like Long Term Disability coverage No Yes

Benefit Amount % to a maximum of $ / month [OR]
% of the 1st $ plus 50% of the balance,
to a maximum of $ / month

Elimination Period 120 days 180 days

Benefit Period to age 65 5 years 2 years

Taxable No Yes

Critical Illness (optional)

Benefit Amount $

Extended Health Care

Deductible No Yes

Co-insurance Drugs % Other Expenses %

Drug Plan Pay Direct Card Reimbursement

Dispensing Fee Deductible No Yes

Per Script Deductible $ per prescription

Paramedical Maximum $ per practitioner

Vision Care No Yes, every 24 months

Employee Assistance Plan

Plan Type Telephonic Plan Full Services Plan

Dental Care

Basic/Preventive Treatments No Yes

Percentage %

Maximum per Calendar Year $

Recall Exam Frequency / 12 months

Major Restorative Treatments (5+ lives) No Yes

Percentage %

Maximum per Calendar Year $ or Combined with Basic

Orthodontic Treatments (10+ lives) No Yes

Percentage %

Lifetime Maximum $

Employee Data Sheet

File Upload
Option 1: Upload your own employee information file here.
Option 2: Download our Employee Data Spreadsheet (XLS), save it to your desktop, enter your information and then upload it.

Add your file here:

Experience and Rates

Health Care

Date : From: Till:

Premiums $ Paid Claims $ Incurred Claims $

Single Rate $ Family Rate $ Couple Rate $

Dental Care

Date : From: Till:

Premiums $ Paid Claims $ Incurred Claims $

Single Rate $ Family Rate $ Couple Rate $

Drugs

Date : From: Till:

Premiums $ Paid Claims $ Incurred Claims $

Single Rate $ Family Rate $ Couple Rate $

Vision

Date : From: Till:

Premiums $ Paid Claims $ Incurred Claims $

Single Rate $ Family Rate $ Couple Rate $

Contact Details

[*] required field.

*Company Name

*Contact Name

Address

City

Province

*Phone

*Email

*Retype Email

Email Proposal to Me No Yes

UNIGROUP - The benefits of understanding. 1-800-292-9066

GROUP INSURANCE QUOTES

Life lnsurance and AD&D

Dependent Life

Short Term Disability (optional)

Long Term Disability (optional)

Critical Illness (optional)

Extended Health Care

Employee Assistance Plan

Dental Care

Health Care

Dental Care

Drugs

Vision