Norbram Group Insurance Benefits Inc.

60 Renfrew Drive, Ste. #340, Markham, ON L3R 0E1
Phone: (905) 479-6711 | Toll Free: 1-800-667-2726
Fax: (905) 940-1266 | Toll Free Fax: 1-888-313-5886
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Employee Benefit Data
Please return by mail or fax to (905)940-1266

Company Name:_________________________Address:____________________________________Postal Code:__________(essential)

Contact Person:_________________________Phone:__________________Fax:________________

 

#
 Name Age Sex

(Male or Female)		 Salary

(Monthly or Annual Income)		 Occupation

(i.e. Office, Admin, Sales, Skilled Labour)		 Workman's Comp

(Yes or No)		 Type of Coverage

W = Waive Health & Dental covered through spouse
F = Family Coverage
S = Single Coverage
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