Quote Request

Please complete parts 1 and 2 below. When you have finished, go to the bottom of the page and click 'Done'. If you have more than 20 employees, simply return to this page after you have clicked "Done" and repeat the process.

Part 1, Contact/Company Information

Contact Name:		Telephone Number:
Company Name:		Fax Number:
Type of Business:		E-Mail Address:
Years in Business:		Postal Code:
Comments:	Questions, comments or additional information.

Part 2, Employee Information

Use the Tab key as a quick way to jump from cell to cell. Shift+Tab jumps backward.

	Employee Name	Date of Birth	Occupation	Gender	Status	Annual Income
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** Waive health and dental coverage (insured through spouse).

Questions? If anything has you puzzled or concerned Keystone Benefits is always happy to help.
Call us at 905.898.6709, toll free at 1.800.486.3259, or use our convenient Web Form.