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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	Fax	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)

Canadian Council of Christian Charities

1-43 Howard Avenue, Elmira, ON N3B 2C9 ■

Email Us■519.669.5137 ■ Mon-Fri 9-5 EST

1-43 Howard Avenue, Elmira, ON N3B 2C9 ■ 519.669.5137 ■ Mon-Fri 9-5 EST

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