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Erb and Erb Insurance Brokers Ltd.

Free, No Obligation, Online Quote

Quotation Request Rorm for the Ontario Crafts Council Group Benefits Program

Please fill out the following
  Ontario Crafts Council Member: Partner or Spouse (if any):
What is your first and last name?
Please input your name
Please input the name of your partner or spouse
What is your email address?
Please input your email address or your phone number
What phone number can we best reach you at during normal business hours?
What is your fax number?
What is your date of birth? (DD-MM-YY)
Please input your date of birth in the proper format
Please input your partner or spouse's date of birth in the proper format
Gender:
Please input your gender
Please input your partner or spouse's gender
Male
Female
Male
Female
What type of coverage would you like quoted?
Please select a type of coverage		 Please check one of the following
a) Single Person coverage
b) Couple coverage (with no children)
c) Single Parent coverage
d) Family (couple with children) coverage
If you would like health and/or dental coverage on children, what are the ages of all the children covered?
Please input the ages of the children to be covered
Child 1: Child 2: Child 3:
Child 4: Child 5: Child 6:
Have you used any tobacco products in the last 12 months?
Please state whether you have used any tobacco products
Please state whether your partner/spouse has used any tobacco products
Yes
No
Yes
No
Do you have any ongoing prescription medication that you are taking?
Yes
No
Yes
No
Please provide details of any pre-existing medical conditions which would be of any concern to an insurance company:

Please choose from the following list of benefits
BENEFITS THAT YOU CAN CHOOSE DESCRIPTION OF BENEFIT Choose Yes or No in each box to indicate which benefits you would like to include for your quotation
Dental Care Pays for various types of dental treatments
Yes No
Yes No
Business overhead expense coverage Pays rent, heat, hydro, telephone etc if the business owner were ever to become disabled
Yes No
Yes No
Disability due to accident Pays monthly income if person cannot work due to accident
Yes No
Yes No
Disability due to illness Pays monthly income if person cannot work due to an illness
Yes No
Yes No
What is/are your specific occupation(s) or the type of craft work that you do?
Please input your specific occupation/craft
Please input your partner/spouse's specific occupation/craft
What is your approximate annual income from all business and employment (after expenses & before taxes):
Please input your approximate annual income
Please input your partner/spouse's approximate annual income
Extended health care Pays for a variety of health care costs including hospital, health practitioners etc.
Yes No
Yes No
Prescription Drug benefits
Please note whether you would like Prescription Drug Benefits
Please note whether your partner/spouse would like Prescription Drug Benefits		 Pays for prescription drugs
Yes No
Yes No
Vision care Pays for eyeglasses and contact lenses
Yes No
Yes No
Term Life Insurance Pays a tax free lump sum at death to named beneficiary or beneficiaries
Yes No
Yes No
Accidental Death benefit Pays a tax free lump sum at death to named beneficiary or beneficiaries where death was accidental
Yes No
Yes No
Accidental fracture benefit Pays a tax free lump sum if you break your arm, leg, hip, etc
Yes No
Yes No
Critical illness benefit Pays a tax free lump sum if you are diagnosed with a serious illness - heart attack, stroke, cancer etc
Yes No
Yes No
Accidental loss of use benefit Pays a tax free lump sum if you lose the use of a limb or sight, speech, hearing etc as the result of an accident
Yes No
Yes No
Post accident adaptation benefit Pays expenses of adapting your home to make it suitable for you as the result of an accident
Yes No
Yes No
Home health care benefit Pays for assistance in the home
Yes No
Yes No
Travel insurance benefit Pays for emergency medical care when you are traveling outside of Ontario
Yes No
Yes No
Life, accidental death & loss of use benefits on children Provides coverage for minor children
Yes No
If you require assistance completing this form or have questions, please call us at 519-579-4270 or 1-800-265-2634 and ask for Jim Kibble or Rob Dubois
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