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 include
Please 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