Group health and dental plans application

Business Name or Occupation

Owner First Name*

Owner Last Name*

Email*

Phone*

Website

Year Business established

Number of employees

Nature of business

Province

Are all employees and owners covered by WSIB?

Are you currently insured by Group Benefit?

Name of the insurance company you have benefit

Company's with two or more employees can design their desirable plans based on what is most suitable to the employer and employees.