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REQUEST FOR QUOTATION FORM * indicates required field *Company Name: *Mailing Address: *City: *Province: *Postal: *Phone: Fax: *Contact Name: *Email Address: 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 Name Smoker Sex Marital Status D.O.B. dd/mm/yy Annual Earn. Occ. Class Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B Choose Yes No Choose Male Female Choose Single Family Choose Class A Class B

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