OASSIS Custom Plan Quote – Information Checklist
Please complete this checklist by gathering the relative documents and then completing the appropriate areas.
Group Name:Contact Name:
Submission Date: Phone:
# of Employees: Email:
Office Use / Does your plan includePlease check if applies / / List Carrier Name
i.e. Sun Life / Claim Experience
(Provide 2 years to
last 6 months)*
Please check if supplied / Rate History
(Provide 2 years to
last 6 months)*
Please check if supplied
Health
Dental
Basic Life
Dependent Life
AD & D
Short Term Disability
Long Term Disability
Employee Assistance Plan
Health Spending Plan
Optional Life Insurance
Other
Please provide plan design(s) booklet(s) for above - Please if supplied
When is your renewal date:
Have you received your renewal?
Cost Sharing Information: % Employer % Employee
Please if supplied
Are any of your covered employees unionized? ______
If yes,how many employeesare unionized? ______
Ifyes,which unions are involved?______
Long Term Disability Statistics (include date of birth, gender, date of disability, status)
Please if supplied Please see page 2 for details
Employee Demographics (include #, names, date of birth, gender, province, salary, marital status, occupation)
Please if supplied Please see page 3 for details (electronic information is acceptable)
Life Insurance Claims (How many in the last two years?)
Please if supplied
Do you have stop loss? if yes please supply detailed information.
Please if supplied
* must be within last 6 months
Long Term Disability Statistics for (group name):______Total # of Employees on Long Term Disability: ______
Date of Birth (m/d/y) / Gender / Date of Disability (m/d/y) / Active/Pending Status
Employee Demographicsfor (group name): ______
Total Number of Employees: ______( if preferred, you can send this in an excel spreadsheet)
Name / Date of
Birth
m/d/y / Gender / Province / Salary / Marital
Status / Occupation
Name / Date of
Birth
m/d/y / Gender / Province / Salary / Marital
Status / Occupation
Name / Date of
Birth
m/d/y / Gender / Province / Salary / Marital
Status / Occupation