Ontario | Ottawa | ADE Financial Group - Insurance and Investment Consultants

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.
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4.
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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.

Our Products and Services

• Life insurance - so your loved ones can always depend on you.
• You can't predict the future, but you can prepare for it with insurance coverage that's right for you.
• Your mortgage may be your largest debt. What happens if your ability to pay it is impacted? Let's talk.
• Critical illness insurance - because the only thing you should have to worry about is getting better.
• Invest in your own future with long term care insurance.
• A disability will change your life and the lives of those around you. Be prepared.
• Invest without surprises through an accumulation annuity.
• Even the squirrels are saving for the future. Start planning for your retirement today.

We represent leading Canadian Insurance and Financial services companies with a full range of products.

Manulife Financial
BMO Life
Canada Life
Empire Financial
Equitable Life
Industrial Alliance
Liberty Health

RBC
Standard Life
Transamerica Life
Unity Life
Unum / Provident
Ontario Blue Cross
Trent Health

and many more...

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