309 - 2540 Shaughnessy Street
Port Coquitlam, BC Canada V3C 3W4
Telephone: 604-464-2712
Fax: 604-464-2715
Toll Free: 1-877-300-8095
Email: info@rwfinancial.com
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Chambers Group Insurance Plan Quote
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Employee Data

Employee 1
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:      * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 
* For business owners "Monthly Earnings" is income after business expenses or income that tax will be paid on.

Employee 2
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 3
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 4
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 5
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 6
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 7
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 8
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 9
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

Employee 10
Name:        Smoker: Yes No     
Occupation:  Sex: Male Female  Birthdate(m/d/y):  
Family Status F=Family S=Single:  * Monthly Earnings: $
Does spouse have group insurance? (place an X where appropriate) Dental:  Health: 

All comments and suggestions appreciated!