* Indicates required information

Section A: Employee Information

Are any of your employees seasonal or part-time?

Are all eligible employees participating in plan?

Are any employees absent from work due to disability, maternity or leaves of absence?

Are your employees covered by Workers Compensation?

Please rank the following benefits in terms of their importance for your plan:

Life Insurance:

Extended Health Care :

Vision Care :

Dental Care :

Short-Term Disability :

Long-Term Disability :

Critical Illness Insurance:

Section B: Company Information

Has your company ever had
a Group Benefits Plan?

If yes, what company? 

Renewal Date:

Name of Business:*

Your First Name:*

  Last Name:*

Position:*

Address:*

 City:*

Province:*

Phone:*

Fax:

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* Yes, I agree to AFG's use of my above personal information to obtain my requested quotation.