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*Company Name:
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*City:
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Fax:
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GROUP LIFE INSURANCE

Proprietors, Officers
& Supervisory Staff:
 
 
2 x annual earnings up to a maximum of $850,000 (Evidence of insurability required for amounts in excess of $600,000)
All Other Employees: 1 x annual earnings up to a maximum of $25,000
ACCIDENTAL DEATH AND DISMEMBERMENT

All Employees
 
 
 
2 x the Group Life Insurance amount
DEPENDENT GROUP LIFE

Spouse

Child(ren)
 
 
 
$5,000

Birth to 13 days - $500
14 days to age 21 - $2,500
DRUG CARD

Annual Deductable:
Managed Health Care Drugs:
Prescription Drugs:
 
 
Nil
80%, 90%, or 100% Co-insurance
80%, 90%, or 100% Co-insurance
  RATES ARE SUBJECT TO REVIEW ANNUALLY (AUGUST 1)
   
Name the Regional Landscape Association you are a member of:
LONG TERM DISABILITY
Waiting Period:
90 days 120 days
Benefit Period: Payable to age 65
OWN OCCUPATION DEFINITION  
Proprietors, Officers & Supervisory Staff:  
3 years
All other employees: 2 years
Monthly Benefits: 70% of monthly earnings to a maximum of $8000
EXTENDED HEALTH CARE
Yearly Deductible:
Hospital:
 
$25 single/$50 family
Semi-private room rate
  Plan pays 100% of Covered Medical Expenses over the deductible amount in any one calendar year.
OPTIONAL BENEFITS: Dental Care
Vision Care
Short Term Disability
*EMPLOYEE DATA REQUIRED FOR COSTING (All Fields Mandatory)
Employee NameSmokerSexMarital StatusD.O.B.
dd/mm/yy
Annual Earn.Occ. Class



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