3i Financial Group Inc

REQUEST FOR QUOTE

Welcome to 3i Financial Group Inc.'s online request for quote. This process is safe and secure and provides an efficient way to offer you and your employees a customized Employer Sponsored Group Health and Dental Benefit Plan.

The online request for quote form will take approximately 10-15 minutes to complete. Once you submit the form electronically, a reference number will be assigned to the request and it will be emailed to you. Within 48 hours a 3i Financial Group Benefits Specialist will contact you.

You are under NO OBLIGATION. The request for quote is absolutely FREE as our role is to shop and to prepare a customized plan just for you and your employees!

Required Application Submitted By
Details
Phone (xxx-xxx-xxxx)

SECTION 1
COMPANY INFORMATION
( Required ) indicates a required field.
  Required Title
   
Contact Name Required First Name
Required Last Name
  Required Company
Required Owner's Name
 
Required Address
Required City
Required Province
Required Postal Code
The email address provided will only be used to send confirmation of the registration. Required Phone (xxx-xxx-xxxx)
Fax (xxx-xxx-xxxx)
Email
SECTION 2
COMPANY DETAILS
  Required Type of Business
# of years in business
 
  # of full time employees (FTE)
   
Min. 20 hours per week # of part time employees (PTE)
  # of employees applying for coverage
# of employees that are related
# of employees working with the company last year
SECTION 3
EXISTING GROUP COVERAGE
Required Do you currently have group coverage?
Yes No    
  Existing Carrier
Effective Date (yyyy-mm-dd)
 
SECTION 4
DESIGN YOUR PLAN
A
Required Life and Accidental
Death and Dismemberment
If Other, please specify:
B
Required Dependent Life

Spouse (S)
Child (C)		 If Other, please specify:
   
C
Required Extended Health Care
Yes No    
    C1   Prescription Drugs
   
  If Other, please specify:
   
   
    C1A   Required Deductible
Yes No
Single (S)
Family (F)		 Deductible Amount
   
  If Other, please specify:
   
   
    C1B   Maximum / Benefit Year
   
  If Other, please specify:
   
   
  NOTE: DRUG CARD INCLUDED
   
    C2   Paramedical Maximum (Per Benefit Year)
   
  If Other, please specify:
   
   
    C3   Required Hospital Care
Semi-Private Private 		   
   
    C4   Required Vision Care
Yes No 		   
  Vision Care coverage for every 2 years
   
  If Other, please specify:
   
   
D Required Dental Insurance
Yes No    
    D1   Dental Coverage
   
  If Other, please specify:
   
   
    D2   Maximum / Benefit Year
   
  If Other, please specify:
   
   
    D3   Choose the Frequency
   
  If Other, please specify:
   
SECTION 5
OPTIONAL COVERAGE
Required Long Term Disability
Yes No    
Benefit
Standard Other    
  Elimination Period
Own Occupation
Benefit Period
   
Required Short Term Disability
Yes No    
Benefit
Standard Other    
  Benefit Period
   
Hospital First Day Coverage
Yes No    
   
Required Critical Illness
Yes No    
Plan Type
Standard Enhanced    
  Benefit
   
Dependent
Yes No    
SECTION 6
QUESTIONS / COMMENTS
  Questions / Comments?
   
Please fill out:

EMPLOYEE DATA SHEET

# Employee Name Occupation DOB Age Sex Salary Date employed Dependent
Status
1 Required Required Required Required Required Required $ Required Required
2 $
3 $
4 $
5 $
6 $
7 $
8 $
9 $
10 $
11 $
12 $
13 $
14 $
15 $
16 $
17 $
18 $
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20 $
21 $
22 $
23 $
24 $
25 $
26 $
27 $
28 $
29 $
30 $
31 $
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34 $
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38 $
39 $
40 $
 
300 West Beaver Creek Rd. Suite 218, Richmond Hill, Ontario, L4B 3B1
Telephone: 905-326-5408     Website: www.3ifinancial.com
Email: