Online Group Benefits Insurance Quote General InformationCompany Name* Do you currently have emplyee benefit plan?* No Yes Do you want the same benefits as the curent plan? Yes No New Plan RequiermentsCurrent Plan End Date DD slash MM slash YYYY Current insurer Required CoverageRequire coverage in* Alberta British Columbia Manitoba New Brunswick Newfoundland & Labrador Northwest Territories Nova Scotia Nunavut Ontario Prince Edward Island Quebec Saskatchewan Yukon Number of employees* 2 3 - 24 25 - 50 51 - 250 251 + Emplyees ListImportant To expedite the quote process please include your employee list. Download the employees list template here Please drop your files in the "Upload files" box in this form.Important To provide you with a comparable offer please include: Employee list (Download the employees list template here ) Employee’s booklet (PDF format) Renewal detailing the claim experience (PDF format) Recent invoice (PDF format)Please drop your files in the "Upload files" box in this form.Upload files Drop files here or Select files Accepted file types: xlsx, pdf, Max. file size: 8 MB, Max. files: 4. I want to enter emplyees information manually Emplyees listFull NameTitle, job & role descriptionSex (M/F)Birth Date (MM-YYYY)Hire Date (MM-YYYY)ClassHours per weekSalary AmountSalary Frequency 1-(A/M/BW/W/H)Indicate if 2-(C/CE/D/IC/R/S/U)Dependent Status (Single or Married)Health 3-(S/C/F/W)Dental 3-(S/C/F/W)Province of Residence 1-Salary Frequency A - Annually M - Monthly BW - Biweekly W- Weekly H - Hourly 2-Indicate if: C - Contractor CE - Commission Employee - indicate Base + Comm amount D - Currently Disabled or not at Work IC - Independent Contractor R - Related to Owner - indicate relationship S - Seasonal Employee - indicate # months worked per year U - Union 3-Health and Dental: S - Single Coverage (Employee only) C - Couple Coverage (Employee + 1 dependent only, spouse or 1 child) F - Family coverage ( Employee and eligible dependents) W - Waiver - Employee can waive coverage, if covered by their spouse's or partner's Health and/or Dental plan Authorization for consultation and quotation mandateNotice of Authorization for consultation and quotation mandate* Consultation mandate Transfer mandate Quotation mandate We hereby appoint David Zohar & GSAQ (hereafter the “New Representative”) as the mandator’s Agent of Record for the following mandate as more fully described below. Consultation mandate We hereby authorized any insurance company or organization responsible for providing our employee benefits plan policy # (provided below) to send to the New Representative the relevant information. The New Representative may request about our existing employee benefits plans so the New Representative can access our file and advise us but not make any amendments thereto. In addition, we confirm that this mandate here by revokes any and all prior mandates given off the same nature.We hereby appoint David Zohar & GSAQ (hereafter the “New Representative”) as the mandator’s Agent of Record for the following mandate as more fully described below. Transfer mandate We would the new representative to take over our entire employee benefits plan file. Weather for asking that all insurance companies or organizations underwriting policy # (provided below) to: Recognize the new representative is the new agent of record for these plans Send a new representative any information about these plans, and Pay the New representative any commissions payable as of (Please select effective date) or date the change in agent of record is made effective at such insurance company or organization in accordance with the company’s policies and procedures. In addition, we confirm that this mandate here by revokes any and all prior mandates given off the same nature.We hereby appoint David Zohar & GSAQ (hereafter the “New Representative”) as the mandator’s Agent of Record for the following mandate as more fully described below. Quotation mandate We hereby authorize any insurance company or any organization responsible for underwriting employee benefits plans to send the new representative a quotation of the rates relating to our group benefits plan. In addition, we confirm that this mandate here by revokes any and all prior mandates given off the same nature.We hereby appoint David Zohar & GSAQ (hereafter the “New Representative”) as the mandator’s Agent of Record for the following mandate as more fully described below. Quotation mandate We hereby authorize any insurance company or any organization responsible for underwriting employee benefits plans to send the new representative a quotation of the rates relating to our group benefits plan. In addition, we confirm that this mandate here by revokes any and all prior mandates given off the same nature.Current Policy Number Transfer mandate effective date DD slash MM slash YYYY Transfer mandate effective dateSignitureName* First Last Email* Phone*Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Signature*Signed at: 120.244.184.59 on 22/12/2024.CommentsCAPTCHA
