Employee Benefit Form

At Ade Financial Group, we understand the challenges businesses face in providing employee benefits. Whether your company has 2 employees or 1000, we can partner with your business to enhance loyalty and job satisfaction by providing excellent benefits or claims service to your employees.

Group Health Quote Request Form Below.

Please fill out this form and submit it to our offices to request a free quote for employee benefits.

COMPANY INFORMATION 
*Company Name:  
*Nature of Business:  
*Years in Business:  
*Company Address: (required) 
*Phone:  
Fax:  
*Contact Person:  
*E-Mail: (required)
Website:  
Present Carrier:  
Effective Date:  
Renewal Date:  


 

HEALTH INFORMATION
Are any employees disabled, or not actively at work?
yes   no
Do you have any reason to believe that any of the employees and/or their dependants are not healthy?
yes   no


 

EMPLOYER CONTRIBUTION INFORMATION
What percentage of these benefits will the company/employee pay?
 
BENEFIT
EMPLOYER
EMPLOYEE
Life
AD&D
W.I.
LTD
Health
Dental
Other
CLASS INFORMATION
Class A Definition:
please fill out Class A section below
Class B Definition:
please fill out Class B section below
CLASS A PLAN DESIGN INFORMATION
Group Life & Accidental Death & Dismemberment
 
Flat Amount of 
 
 
OR
 
 
times annual earnings
 
 
 
 
Dependent Life Insurance
 
 
 
$5,000 spouse / $2,500 child
 
$10,000 spouse / $5,000 child
 
  
Weekly Indemnity
  Not Required    
  Taxable  Non-Taxable  60%       66.67%    graded
  day accident      day sickness
  (# weeks) benefit period      weekly maximum
  First Day Hospital  yes   no
   
Long Term Disability
  Not Required    
  Taxable  Non-Taxable   60%       66.67%    graded
  starts after 17 weeks   26 weeks
  pays for 2 years   5 years to age 65
  maximum monthly benefit   non-evidence maximum
  2 year own occ      any occ to age 65
   
Extended Health Care
  Not Required 
Co-Insurance   80%  80% Drugs/100% other   100%
Annual Deductible   Nil  $25/$25 $25/$50  $50/$50 $50/$100
Dispensing Fee Deductible  Nil   Other   
Paramedic Practitioners   $250 each year   $500 each year   Other  
Pay Direct Drug Card?    yes   no
Out of Country?   yes   no
Survivor Benefits?  yes   no
   
Vision Care
  Not Required 
  Include exams?   yes   no
Maximum amount per 24 months 
$75  $100   $150   $200   Other   
   
Dental Care
  Not Required 
Annual Deductible   Nil  $25/$25 $25/$50  $50/$50 $50/$100
 
Basic Reimbursement
Basic:  100%  80%
Major:  Nil  50%
Orthodontia:  Nil  50%
 
Annual Maximums
Basic:  Unlimited  $1,000  $1,500
Major:  $1,000  $1,500   $2,000
Combined:  $1,000  $1,500   $2,000   $2,500
 
Lifetime Maximum - Orthodontia
$1,000  $1,500   $2,000
CLASS B PLAN DESIGN INFORMATION
Group Life & Accidental Death & Dismemberment
 
Flat Amount of 
 
 
OR
 
 
times annual earnings
 
 
 
 
Dependent Life Insurance
 
 
 
$5,000 spouse / $2,500 child
 
$10,000 spouse / $5,000 child
 
  
Weekly Indemnity
  Not Required    
  Taxable  Non-Taxable   60%       66.67%    graded
  day accident     day sickness
  (# weeks) benefit period      weekly maximum
  First Day Hospital  yes   no
   
Long Term Disability
  Not Required    
  Taxable  Non-Taxable    60%       66.67%    graded
  starts after 17 weeks   26 weeks
  pays for 2 years   5 years to age 65
  maximum monthly benefit    non-evidence maximum
  2 year own occ      any occ to age 65
   
Extended Health Care
  Not Required 
Co-Insurance    80%  80% Drugs/100% other   100%
Annual Deductible    Nil  $25/$25 $25/$50  $50/$50 $50/$100
Dispensing Fee Deductible   Nil   Other   
Paramedic Practitioners   $250 each year   $500 each year   Other  
Pay Direct Drug Card?    yes   no
Out of Country?   yes   no
Survivor Benefits?  yes   no
   
Vision Care
  Not Required 
  Include exams?   yes   no
Maximum amount per 24 months  
$75  $100   $150   $200   Other   
   
Dental Care
  Not Required 
Annual Deductible  Nil  $25/$25 $25/$50  $50/$50 $50/$100
 
Basic Reimbursement
Basic:  100%  80%
Major:  Nil  50%
Orthodontia:  Nil  50%
 
Annual Maximums
Basic:  Unlimited  $1,000  $1,500
Major:  $1,000  $1,500   $2,000
Combined:  $1,000  $1,500   $2,000   $2,500
 
Lifetime Maximum - Orthodontia
$1,000  $1,500   $2,000
Employee's Name
Occupation
DOB
Salary
S/F/W
Prov.
Class
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
COMMENTS, QUESTIONS OR OTHER DETAILS
Please provide any additional information that you may think is necessary.
By submitting this form, I/WE CERTIFY THAT all of the answers above are correct and complete. We hereby appoint Ontario Health Quotes to act as the representative and Agent of Record to obtain quotations for our company’s employee group benefit program.

Ontario Health Quotes will serve as the Agent of Record for all quotations received from all insurers submitting such quotations. Please provide Ontario Health Quotes with all the necessary information they are requesting and forward any questions you may have to them.
 
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