Chamber of Commerce Group Insurance Plan for Atlantic Canada

	CONFIDENTIAL EMPLOYEE DATA

Business Name: _____________________________________ Date:__________________
Business Address: ___________________________________________ Contact Name:_____________________
____________________________________________
Telephone No.: ______________________ Fax No.:____________________ Email:_____________________


	Employee Name	Date of Birth (YYYY-MM-DD)	Occupation	S=Single F=Family C=Couple	*Presently covered on Spousal Plan	Monthly Earnings
					Health Dental
	John Smith	1965-02-27	Consultant		No No	$2,600
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If employee is "currently covered" for health and dental benefits under a spouse's plan answer YES.

To obtain a quote, please print this page, complete it and fax to your "Exclusive" agent.