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Please complete the information in this form, and we will get back to you with a quotation on a plan for your business.

If you have more employees than our form can accommodate, please use our contact form to get in touch with us and we will contact you directly.
Company Name  
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Contact Name  
Phone  
Fax  
Email  
  List Auto Clubs and Towing Associations you belong to
  Please list all employees working at least 20 hrs per week and 10 months per year
  Employee Name Date of Birth (DD/MM/YY) or age Occupation Salary (Yearly or Monthly) Health & Dental Coverage Covered by Worker's Comp? Covered by Employment Insurance?
1 No Yes No Yes
2 No Yes No Yes
3 No Yes No Yes
4 No Yes No Yes
5 No Yes No Yes
6 No Yes No Yes
7 No Yes No Yes
8 No Yes No Yes
9 No Yes No Yes
10 No Yes No Yes
11 No Yes No Yes
12 No Yes No Yes
13 No Yes No Yes
14 No Yes No Yes
15 No Yes No Yes
* - If covered through spouse

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