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VERSION DATE: FEBRUARY 2015
BENEFIT
REQUEST TO QUOTE
AVAILABLE TO GROUPS WITH 2-19 ELIGIBLE EMPLOYEES
Producer:
Producer Code (if applicable):
Group Office:
Current Date:
Phone number:
Fax number:
Producer Email Address:
BEN-0014-ENG-02/15
REQUEST TO QUOTE
1
Reset Form
Policyowner/Applicant (Exact Legal Name):
O Name Above O Other:
What name should appear on your Employee Booklets and Benefit Cards?
2
Address (number, street):
City
3
Province
Postal code
Plan Administrator #1(Name):
Telephone
Fax
Email Address
Plan Administrator #2 (Name):
Telephone
Fax
Email Address
Plan Administrator #3 (Name):
Telephone
Fax
Email Address
Plan Administrator #4 (Name):
Telephone
Fax
Email Address
4
Type of Business (Goods or Services Provided):
5
Ownership (Check one):
O Sole Proprietorship O Partnership O Corporation O Limited Liability Partnership
Name(s) of Owner(s), if Sole Proprietorship, Partnership or Limited Liability Partnership:
6
Affiliated Companies to be included (Print exact legal name(s)) O Yes O No
If more than 2 affiliated companies, complete and attach a list of affiliated companies.
Is billing sub-totalling required?
O
Yes O
No
Affiliated company #1
Name:
Address (number, street):
City
Province
Postal code
Affiliated company #1 Plan Administrator (name):
Telephone
Fax
Email address
Business relationship to Policyowner:
O Common Ownership O Subsidiary O Other:
Nature of Business:
Number of Employees in affiliated company #1:
Affiliated company #2
Name:
Address (number, street):
City
Province
Postal code
Affiliated company #2 Plan Administrator (name):
Telephone
Fax
Email address
Business relationship to Policyowner:
O
Common Ownership
O
Subsidiary
O
Other:
Nature of Business:
Number of Employees in affiliated company #2:
7
REQUESTED EFFECTIVE DATE for all coverage is 12:01 a.m. Standard Time on:
(day),
8
2 of 12
(month),
(year).
FIRST YEAR RENEWAL DURATION: 15 months
BEN-0014-ENG-02/15
EMPIRE LIFE COPY
9
Present Coverage
To avoid a period without coverage, do not terminate any existing coverage until notice has been given in writing that the coverage
being applied for is approved by The Empire Life Insurance Company (the effective date will normally be the first day of the month
following approval).
When applying for a Group Benefit Plan with The Empire Life Insurance Company (Empire Life), the Applicant must obtain individual
plan member consent for the collection, use and disclosure of plan member personal information (including personal information
about plan member dependant(s)) required for plan enrolment and ongoing administration of the plan.
Will the insurance applied for replace similar insurance?
O
Yes
O
No
If Yes, complete this section, and provide a full copy of your most recent billing statement.
Benefit Name of Current Carrier Issue Date Proposed Cancellation Date
O
Life and A.D.&D.
O
Dependant Life
O
Optional Employee Life
O
Group Critical Illness
O
Weekly Indemnity
O
Long Term Disability
O
Extended Health
O
Dental
Healthcare Pooling
Is your current coverage eligible for Extended Healthcare Policy Protection Plan (EP3) pooling?
O Yes O No – If yes, please provide your most current Inter-Company EP3 Statement
10 How long has the current employer owned the business?
11
Describe the classification of employees who will be eligible for benefits. O Class A – All employees or specify
Class A ______________________________________________________________________________________________________
Class B ______________________________________________________________________________________________________
Note: A minimum of 3 insured lives is required for 2 Classes.
12 Definition of salary O Basic salary only O Base salary plus commission (2 year average)
O Dividends included in Owners and/or Executives definition of salary (3 year average).
Note: Bonuses are excluded from definition of earnings and will not be covered.
13 Eligible Employees
What is the minimum number of hours per week that Employees must work to be considered eligible? Note that the lowest
allowable figure is 20 hours per week and that the employees must be active, reside in Canada, and be employed on a permanent
basis in Canada. ____________ hours.
Total Number of Employees to be insured as of the Policy Effective Date*:
Total Number of Employees on payroll as of the Policy Effective Date*:
* If there are employees not included in the plan, please explain below:
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EMPIRE LIFE COPY
14 Participation Requirements:
a) If this plan has 2 – 9 insured employees, 100% participation is required.
b) If this plan has 10 – 19 insured employees and the employer contributes 100% of the overall premiums,
100% participation is required.
c) If this plan has 10 – 19 insured employees and the employer contributes a minimum of 50%* but less than 100% of the overall
premiums, select from the following participation options: O Mandatory
O Non-Mandatory
* Employer is required to contribute at least 50% of the overall premiums (25% in province of Quebec) excluding any individual
Optional premiums.
The Policyowner will be paying the following percentage for each benefit:
Class A
Percentage
Class B
Percentage
Life/A.D.&D.
%
Life/A.D.&D.
%
Dependant Life
%
Dependant Life
%
VItal Assist Health Benefit
%
VItal Assist Health Benefit
%
Weekly Indemnity
%
Weekly Indemnity
%
Long Term Disability
%
Long Term Disability
%
Extended Health
%
Extended Health
%
Dental
%
Dental
%
Disability benefits (Weekly Indemnity or Long Term Disability) are taxable if the employer pays a portion of the premium for the
benefit. Note that if a 70% or 75% Weekly Indemnity or Long Term Disability schedule is desired, the plan must be taxable, and
therefore the employer must pay a portion of the Weekly Indemnity or Long Term Disability premium. The taxable/non-taxable
status of disability benefits cannot vary by employee class.
15 Waiting Period
1 month of continuous employment
3 months of continuous employment
6 months of continuous employment
12 months of continuous employment
Class A
Class B
Waiting period to apply to:
O
O
O
O
O
O
O
O
O Future employees only, or
O Present and future employees.
New enrolments must be received by Empire Life no later than 31 days after the completion of the waiting period.
16 Are there any employees employed on a contract, consultant, sub-contractor, or seasonal basis applying for coverage under
this plan?
O
Yes
O
No
If Yes please identify:
17 How many of the employees applying for coverage under this plan are covered by provincial workplace safety legislation
(e.g. WSIB/WCB/CSST)?
18 a) How many individuals included with this Application are applying for LTD?____________________________________
b) How many of the individuals noted in 18 a) are related to the owner(s) of any eligible company (i.e., spouse, parent, child, sibling)?
Please include the owner(s) in your total:____________________________________
19 Are all business locations totally separate from all company owners’ residences (will allow a home based business providing there is
a physical separation from living area)?
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BEN-0014-ENG-02/15
O Yes O No
EMPIRE LIFE COPY
20 a) How many employees are currently absent from work due to disability? _______
List the employee(s) and indicate date of disability, age and (expected) date of return to work. Also indicate if the employee has been
approved for any workplace safety benefits (e.g. WSIB/WCB/CSST), Weekly Indemnity, Employment Insurance, Long Term Disability,
and/or Life Waiver of Premium
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
b) Is any employee absent from work due to layoff?
O
Yes
O
No
If yes, please provide name(s), date laid off and expected date of return to work
_____________________________________________________________________________________________________ _____________________________________________________________________________________________________ _____________________________________________________________________________________________________
21 If your company is primarily based in a province other than Quebec:
b) Do you have a physical business location (e.g. branch, warehouse, sales office) in the province of Quebec?
O Yes O No
O Yes O No
c) If you do not have a physical business location in Quebec, do you wish to provide your Quebec
residents with drug coverage that complies with the Quebec Universal Drug legislation?
O Yes O No
a) Do any employees have their principal residence in Quebec?
Termination Age: Life, AD&D, and Dependant Life terminate at the Insured Employee’s age 75 or prior retirement. Long Term
Disability, Optional Life, Optional AD&D and Vital Assist Health Benefit terminate at the Insured Employee’s age 65 or prior
retirement, and Weekly Indemnity terminates at the Insured Employee’s age 70 or prior retirement. Health, Dental, and HCSA
terminate at the same age according to the options in Section 28.
22 Percentage of Employer contribution of overall premium (must be a minimum of 50% (25% in Quebec)). _______%
Percentage of Employer contribution to WI premium _______ (0% for non-taxable)
Percentage of Employer contribution to LTD premium _______ (0% for non-taxable)
PLAN DESIGN
23 O Base Plan O Alternative Plan
A minimum of 3 Insured Lives is required for 2 classes. A minimum of 2 Optional benefits must be elected.
If more than one class is required, please complete a separate request to quote for each class.
24 For Groups with 2-3 lives, a minimum of 2 Optional Benefits must be elected (excluding AssistNow EAP).
O Basic Life and AD&D (Mandatory)
Maximum Coverage
1x Annual Salary*
2x Annual Salary*
3x Annual Salary*
O
O
O
O $900,000
or $
Flat Amount* of (indicate amount)
$
Reduction Clause: Reduces to $30,000 at age 65 and further reduces to $15,000 at age 70.
* The minimum coverage is $30,000. Overall maximum is $900,000.
Employee Accidental Death & Dismemberment Rate, all ages (per $1,000 of insured volume): $ .05
Basic Life Rate (per $1,000 of insured volume): $
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EMPIRE LIFE COPY
25 O Employee Optional Life and A.D.&D. Units of $25,000 available to each eligible person
O No Coverage
Optional Life Rates (per $1,000 of insured volume):
Age of Employee
Male
Female
Smoker
Non-smoker
Smoker
Non-smoker
<30
$ .12
$ .07
$ .06
$ .04
30-34
.12
.07
.08
.05
35-39
.17
.09
.11
.07
40-44
.27
.15
.19
.11
45-49
.45
.23
.29
.16
50-54
.71
.37
.42
.24
55-59
1.19
.64
.64
.38
60-64
1.79
.97
.96
.58
Employee Optional Accidental Death & Dismemberment Rate, all ages (per $1,000 of insured volume): $ .05
26 Dependant Life (Mandatory) $10,000 spouse / $5,000 child
For Groups with 2-3 lives, a minimum of 2 optional benefits must be selected (excluding AssistNow® EAP)
27 O Vital Assist Health Benefit (Payable once per lifetime benefit) (optional) O No Coverage
Cannot select different options for different employee classes with one exception: No coverage for one class and Option A for another
O Option A – $10,000
O Option B – $20,000
O Option C – $30,000
- Minimum of 5 lives under age 65
- Minimum of 10 lives under age 65
- Minimum of 15 lives under age 65
- Maximum benefit $10,000 ($5,000
lump sum + $5,000 medical
expense benefit)
- Maximum benefit $20,000
($15,000 lump sum + $5,000 medical
expense benefit)
-M
aximum benefit of $30,000 ($25,000 lump
sum + $5,000 medical expense benefit)
O Coverage applies to class_____ only
28 O Weekly Indemnity (Optional) (Weekly Indemnity and Long Term Disability must have the identical tax status) O No Coverage
Percentage of earnings:
O
60% O
O
O
O
O
EI Max
O
662/3%
O
O
70%*
75%*
Maximum Weekly Benefit
Maximum - 2 lives:
Maximum 3-4 lives
Maximum - 5-9 lives:
Maximum - 10 -14 lives:
$2,200
EI Max
EI Max
O
O
O
$700
$700
$700
O
O
O
$800
$900
$800
O
O
O
O
$800
O
$800
$1,000
$900
O
O
O
$900
O
$900
$1,250
$1,000
O
O
O
$1,250
O
O
O
$1,750 O $2,000 O $2,200
$1,000
O
$1,250
O
$1,750
$1,000
O
$1,250
O
$1,750O $2,000 O $2,200
$1,000
$1,250
_______ Other
$1,750 O _______ Other
_______ Other
EI Max
O
$700
O $2,500 O _______ Other
Maximum - 15 -19 lives:
O EI Max O $700 O $800 O $900 O
O $2,500 O $2,800 O _______ Other
Elimination Period:
O 0/7/17 O 0/7/26
O 14/14/15
st
1 Day Hospital/Outpatient Surgery:
O Yes O No
Tax status:
O Taxable O Non-taxable O
$2,000 O
O
14/14/26
* P
lans with 70% or 75% benefit must be taxable. All covered classes must have the same schedule and 1st Day Hospital/Outpatient Surgery option.
Termination age 70.
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EMPIRE LIFE COPY
29 O Long Term Disability (Optional) (Weekly Indemnity and Long Term Disability must have the identical tax status) O No Coverage
Percentage of earnings: Benefit period:
O
2 years
O 60% O 662/3% O 70%**
O 75%**
O Graded schedule ____% of the first $______;____% of the next $______, and ____%
O 5 years O To Age 65 (less elimination period)
of excess
Maximum Monthly Benefit
O $5,000 or $_______
5-9 Lives:
O $7,000 or $_______ Two year Own Occupation included.
10-14 Lives: O $8,000 or $_______ Two year Own Occupation included.
15-19 Lives: O $10,000 or $_______ All covered classes must have the same Elimination Period and Benefit Period.
Survivor BenefitO None
O 3 months O 6 months
Tax status (can vary by class):O Taxable O Non-taxable
Elimination period:
O 15 weeks O 17 weeks O 26 weeks
2-4 Lives:
**Plans with 70% or 75% benefit must be taxable.
30 O Extended Healthcare (optional)
Benefit Period
Termination Age (also
applies to Dental)
O No Coverage
O Benefit Year O Calendar Year
O 60 O 65 O 70 O 75 O 80 O 85
Survivor Benefits
Included for 2 years
Healthcare Pooling
$7,500 per certificate per benefit year for all EHB benefits, excluding Emergency Travel Assistance Program
Empire Life participates in the drug pooling agreement offered by the Canadian Drug Insurance Pooling Corporation (CDIPC).
The CDIPC requires fully insured drug benefit plans to include pooling protection, called an EP3. Some claims may be ineligible
for EP3 and, if so, Empire Life will provide a Large Amount Pooling (LAP) arrangement.
When selecting Drug and Major Medical coverage, customers have the option between EHB Standard Coverage and
Healthcare Essentials. Both classes must be insured for the same Drug and Major Medical benefits. Classes can differ by
deductible, coinsurance, or maximum.
Pay Direct Drug Plan
Extended Health Benefits will be administered in accordance with the requirements of applicable provincial drug insurance
legislation, and will meet any minimum coverage standards.
Plan Type
O Brand Name O Generic Substitution
O Provincial Formulary**
O Mandatory Generic Substitution*
*Not applicable to employees and/or eligible dependants residing in Quebec.
** If Provincial Formulary is chosen, the two tier coinsurance is 100% Formulary Drugs/80% Non Formulary Drugs
Coinsurance
Flat, OR
Tiered: Generic Drugs/
Brand Name Drugs, OR
O 60% O 70% O 75% O 80% O 90% O 100%
O 100% /80% O 90% /70% O 80% /60%
Graded
O 80% of first $5,000, 100% thereafter
Deductible
Choose one of the following:
Annual (Single/Family), or
O $0/$0 O $25/ $50 O $50/$100 O $100/$200 O $250/$500
O $0/$0 O Dispensing Fee O $5 O $10 O Other _____ ($1 to $20 in $0.50 increments)
O Empire Life R&C (Default) O Other _____ ($1 to $20 in $0.50 increments)
Per Prescription, or
Dispensing Fee Maximum
Maximum
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Brand, Generic, and
Mandatory Generic
Substitution Plans
O Unlimited O $5,000 O $7,500 O $10,000
O $ _____ Other ($500 to $10,000, increments of $500)
Provincial Formulary Plans
O Unlimited
BEN-0014-ENG-02/15
Applicable to all drugs except: Smoking Cessation ($300 maximum), Fertility (50% coinsurance, $4,000
lifetime maximum), Sexual Dysfunction ($1,000 maximum)
EMPIRE LIFE COPY
30 Major Medical
O Option 1: Standard Extended Health Benefit
Coinsurance
Applicable to Major Medical,
except Hospital, Vision
Care, Eye Exam, Out of
Province Emergency
Deductible
Paramedical Services
O 60% O 70% O 75% O 80% O 90% O 100%
O _____% Other (50% to 100% in increments of 5%)
$0/$0
O
Yes
O No
Included Practitioners
Acupuncturist
Audiologist
Chiropractor
Christian Science Practitioner
Registered Clinical Psychologist
Annual Maximum, OR
Includes first dollar top-up unless NOT allowed by Provincial Regulation
Insured Basis
O Per Certificate O Per Insured
O Per Practitioner O All Practitioners combined
O $300 O $500 O $700 O $1,000 O Other _____ ($300 to $3,000 maximum in $100 increments)
Practitioner Basis
Dollar Amount
Chiropodist
Naturopath
Occupational Therapist
Osteopath
Podiatrist
Physiotherapist
Registered Dietician
Registered Massage Therapist
Social Worker
Speech Therapist
Per Visit Maximum
Maximum Basis
Per Insured, Per Practitioner
Dollar Amount
O None O $50 O $75 O Other _______ ($25 to $175 maximum in $5 increments)
Diagnostic Laboratory
Procedures
Semi-Private Hospital
O $500 O$1,000 O $1,500
O Yes (100% Coinsurance) O No
Convalescent Hospital
Included, Coinsurance matches Major Medical, $20/day and 120 duration maximum, per insured
Specialized Treatment
Facility
Included, 50% coinsurance, $4,000, per insured, lifetime maximum
Eye Exams
O Yes (100% Coinsurance)
O No
O $75 (Default) O $100 O $150
Maximum, Per Insured
Maximum, Per Insured
O Other _______ ($50 to $200 maximum in $25 increments)
Every 12 months for dependent child/ 24 months for adult
Vision Care
O Yes (100% Coinsurance) O No
Available to groups with 4 or more employees
(requires a minimum of 4
lives)
Maximum, Per Insured
O $100 O $150 O $200 O $250 O $300 O Other _______
($100 to $500 maximum in $25 increments) Every 12 months for dependent child/ 24 months for adult
$100 and $150 maximums will be extended to $200 over 12/24 months for contact lenses (if necessary
for 20/40 visual acuity).
Orthopaedic Supplies
Maximum
Shoes
O $200 (Default) O $300 O $400 O $500 O Other _______ ($50 to maximum of $1,000 in $50
increments)
Inserts
O $200 (Default) O $300 O $400 O $500 O Other _______
($50 to maximum of $1,000 in $50
increments)
Combined Maximum
O $500 O $700 O $800 O Other _______
($200 to maximum of $1,500 in $100 increments)
Private Duty Nursing
Maximum, Per Insured
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BEN-0014-ENG-02/15
O $5,000
O $10,000
O $15,000
O $20,000
O $25,000
EMPIRE LIFE COPY
30 Emergency Travel Assistance Program
Termination Age
Matches EHB
Coinsurance
100%
Deductible
$0/$0
Trip Duration
O 60 days
Lifetime Maximum
$5,000,000, Per Insured
Out-of-Province Referral
Lifetime Maximum
$15,000 (combined), Per Insured
Travel Assistance
Included
O 90 days
O 120 days continuous coverage
O Option 2: Healthcare Essentials (both classes are covered, where applicable)
Optional Benefits
O Include (100% Coinsurance) O Exclude
Included
Semi-Private Hospital, Paramedical Services, Vision, Eye Exams, and Medical Supplies
Deductible
$0/$0
Combined Maximum, per
certificate
O $500 O $1,000
Mandatory Benefits
Private Duty Nursing
Included at 100% coinsurance, $10,000 maximum
Pay Direct Drug Plan
The benefit options selected under Drugs will apply with the exception of the following:
With Optional Benefits,
excludes
Without Optional Benefits,
excludes
Emergency Travel
Assistance program
Sexual Dysfunction, Fertility Drugs
Smoking Cessation, Sexual Dysfunction, Fertility Drugs
100% Coinsurance, Trip Duration 60 days, $5,000,000 Lifetime Maximum, per insured
Incidental Health Expense (Optional)
Can be selected with Standard Extended Health or Healthcare Essentials
Single $ ______________ (per benefit period)
Family $ ______________ (per benefit period)
Benefit amount selected can vary, beginning at $100, to a maximum of $3,000, per benefit period, in multiples of $25.00.
Termination age 75.
EHB Health Benefit Rates $ ________
Single $________Family
31 O Health Care Spending Account (HCSA) (Optional)
Health Care Spending Account available only to Incorporated Companies.
Coverage does not have to apply to all classes, but must apply to all insured employees within a class.
Standard Funding Option: Monthly reconciliation
Benefit Period:
Grace Period:
O Calendar year O Benefit year
O 90 day O 180 day
Select either Balance Carry Forward account type or No Balance Carry Forward account type:
O Balance Carry Forward
Prorate allocation amounts for new employees
Coordination with EHB and Dental 9 of 12
BEN-0014-ENG-02/15
Class A
O
O
Yes O
Class B
No
Yes (recommended)
O
No
O
O
Yes
O
No
Yes (recommended)
O
No
EMPIRE LIFE COPY
31 Amount:
O Annual
O Annual
Benefit amount can vary beginning at
$100 to a maximum of $10,000 annually
OR
Single $ _______ (per benefit period)
Single $ _______ (per benefit period)
Family $ _______ (per benefit period)
Family $ _______ (per benefit period)
$50 to a maximum of $2,500
quarterly/semi-annually
O Semi Annual
O Semi Annual
Single $ _______ (per benefit period)
Single $ _______ (per benefit period)
Family $ _______ (per benefit period)
Family $ _______ (per benefit period)
O Quarterly
O Quarterly
Single $ _______ (per benefit period)
Single $ _______ (per benefit period)
Family $ _______ (per benefit period)
Family $ _______ (per benefit period)
O No Balance Carry Forward
Class A
Prorate allocation amounts for new employees
Coordination with EHB and Dental Amount:
Benefit amount can vary beginning at
$100 to a maximum of $10,000 annually
O
O
Yes O
Class B
No
Yes (recommended)
O
No
O
O
Yes
O
No
Yes (recommended)
O
No
Single $ _______ (per benefit period)
Single $ _______ (per benefit period)
Family $ _______ (per benefit period)
Family $ _______ (per benefit period)
32 O AssistNow® EAP (Optional) (In collaboration with Aspiria Corporation)
Services for employees and their dependants:
Services for business leaders and managers:
• Counselling
• Work life and wellness web portal
• Management consultation
• Trauma response service
• Life coaching
• Smoking cessation treatment
• Monitored referral program
• Utilization reports
33 O Dental - Standard
O Insured O Administrative Services Only O No coverage
Either Insured or ASO is applicable to all classes
Benefit Period
Matches EHB Benefit Period
Survivor Benefit
Included for 2 years
Maximum Basis
Basic Restorative,
Periodontic-Endodontic,
Major Restorative
Orthodontic
O Per Insured
O Per Certificate
Per Insured
Basic Restorative and Periodontic-Endodontic
Deductible
Coinsurance
Maximum
Scaling Units
(1 unit = 15 mins)
Recall
O $0/$0 O $25/ $50 O $50/ $100
O 60% O 70% O 80%
O 90% O 100%
O $750 O $1,000 O $1,500 O Other $ _______ ($500 to $5,000 in increments of $250)
O 12 units
O 15 units
O Other _______ (6 to 16, increments of 1)
Year
O 6 months O 9 months
O 12 months
O Standard (Default) O Deluxe (additional 25%)
O Current O Fixed (Provide Year)
Practitioner
General Practitioner
Province
Fee Guide
Major Restorative
O Employee province of residence (Default)
O Policyowner’s province of primary business location
O Yes O No
Eligibility
Requires a minimum of 4 insured lives for Dental
Deductible
Applies as above
Coinsurance
50%
Maximum
O $750 O $1,000 O $1,500
10 of 12 BEN-0014-ENG-02/15
O Other $ _______
($500 to $5,000 (increments of $250)
EMPIRE LIFE COPY
33 Combined with Basic
Restorative, PeriodonticEndodontic, and Major
Restorative
O Yes O No
Deductible
O Yes O No
In order to be eligible for Orthodontic, there must be a minimum of 5 insured lives and Major
Restorative must be selected. Coverage is for dependent children up to and including age 19.
$0/$0
Coinsurance
50%
Maximum (per lifetime)
O $1,000
Orthodontics
Eligibility
O $1,500
O $2,000
O $2,500
34 O Dental Flex
O Insured O Administrative Services Only (AS0) O No coverage
Combined Basic & Restorative, Periodontic-Endodontic, Major Restorative & Orthodontic – If Dental Flex is selected, both classes
must be insured or ASO
Eligibility
Requires a minimum of 2 insured lives Orthodontic coverage is for dependant children up to and
including age 19.
Benefit Period
Matches EHB Benefit Period
Survivor Benefit
Included for 2 years
Maximum
Annual Combined Maximum
O Per Insured O Per Certificate
O $750 O $1,000 O $1,500 O Other $ _______
Deductible
$0
Coinsurance
O 80% O 100%
O 12 units
O 15 units
Maximum Basis
Scaling Units
(1 unit = 15 mins)
Recall
($500 to $3,000 (increments of $250)
O Other ______ (6 to 16 units, 1 unit increments)
Year
O 6 months
O 9 months
O 12 months
O Standard Fee Guide O Deluxe Fee Guide (additional 25%)
O Current O Fixed (Provide Year)
Practitioner
General
Province
O Employee province of residence (Default)
O Policyowner’s province of primary business location
Fee Guide
35 General Information
Waiting period: O 1 month
O 3 months O 6 months O 12 months
Cost Plus is included in all contracts.
If more than one class is chosen, a separate waiting period is allowed for each class. Quoted rates are an illustration only.
Actual rates will be determined based on enrolment data.
11 of 12 BEN-0014-ENG-02/15
EMPIRE LIFE COPY
36 Employee Data (20 hours or more per week) Exclude part time.
Sex
Employee
M or F Age
Salary
Frequency
A,W, H, M
Bi-wkly
Occupation
Contract
Ext.
Spousal
Employee Health Dental Opt.
Marital
Y or N
S or F S or F
outs Prov. Status
Date
of Hire
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
Registered trademark of The Empire Life Insurance Company.
Policies are issued by The Empire Life Insurance Company.
®
12 of 12 BEN-0014-ENG-02/15
EMPIRE LIFE COPY