REQUEST A QUOTE

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For 10 or less employees you may use this form to obtain a quote.

For 11 or more employees please use the print version of this form and fax to (905)940-1266.

Norbram Group Insurance Benefits Inc.

Please submit on line or print and return by fax to 905-940-1266

 

Company Name*:       Postal Code*:       (* = required field)

         

Contact Person*:       Phone*:                      Fax:  

 

#	NAME	Birth Date mmddyy	SEX (Male or Female)	SALARY Monthly or Annual Income	OCCUPATION (ie Office, Admin., Sales, Skilled Labour)	Contract Employee Yes/No	TYPE OF COVERAGE W –  Waive Health & Dental covered through Spouse F – Family Coverage S – Single Coverage C – Couples Coverage SP – Single Parent
1			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
2			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
3			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
4			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
5			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
6			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
7			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
8			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
9			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent
10			--- Male Female	--- Monthly Annual	--- Amininstration Office Sales Skilled Labour	--- No Yes	--- W- Waive Health & Dental (covered through spouse) F- Family Coverage S- Single Coverage C- Couples Coverage SP- Single Parent

 

                                                                                               60 Renfrew Drive, Ste. #340, Markham, ON   L3R 0E1

                                                                          Phone: (416) 798-4974                Phone:  (905) 479-6711         Toll Free: 1-800-667-2726

                                                                             Fax:  (905) 940-1266                Toll Free Fax:  1-888-313-5886