Group Health Quote Request

Want to learn more about our Employees Group Health Insurance plan? Complete and submit this form, and we'll send you a quote within one business day.

Organization Information

Name of Church or Organization		Denominational Affiliation, if any
Name of Contact Person		Title
Address		City	Province	Postal Code
Organization Phone	Contact Phone	Email

Employees

Please do not list family members; only full-time employees (minimum 20 hours per week)

Employee		Sex	Date of Birth (dd/mm/yyyy)	Marital Status	# of Depend. Children	Status in Canada	Full- Time?	Base Earnings (Year, Month, Week)