<% If Request("mode").count > 0 then Dim v_company Dim v_address Dim v_contact Dim v_tel Dim v_fax Dim v_bus_type Dim v_emp_cnt Dim v_years_bus Dim v_homebased Dim v_cur_benefits_EIC Dim v_cur_benefits_CPP Dim v_cur_benefits_WCB Dim v_provide_plan Dim v_provide_rrsp Dim v_ins_company Dim v_renew_dt Dim v_accidental Dim v_dependant Dim v_ltd Dim v_ext_health Dim v_dent_cov Dim v_emp_name Dim v_salary Dim v_sal_type Dim v_sex Dim v_dep_status Dim v_dob Dim v_prov Dim v_job_title Dim v_job_class Dim v_ehs Dim v_dental Dim v_emp_date Dim v_cur_disabled v_company = "" & Request.Form("company") v_address = "" & Request.Form("address") v_contact = "" & Request.Form("contact") v_tel = "" & Request.Form("tel") v_fax = "" & Request.Form("fax") v_bus_type = "" & Request.Form("bus_type") v_emp_cnt = "" & Request.Form("emp_cnt") v_years_bus = "" & Request.Form("years_bus") v_homebased = "" & Request.Form("homebased") v_cur_benefits_EIC = "" & Request.Form("cur_benefits_EIC") v_cur_benefits_CPP = "" & Request.Form("cur_benefits_CPP") v_cur_benefits_WCB = "" & Request.Form("cur_benefits_WCB") v_provide_plan = "" & Request.Form("provide_plan") v_provide_rrsp = "" & Request.Form("provide_rrsp") v_ins_company = "" & Request.Form("ins_company") v_renew_dt = "" & Request.Form("renew_dt") v_accidental = "" & Request.Form("accidental") v_dependant = "" & Request.Form("dependant") v_ltd = "" & Request.Form("ltd") v_ext_health = "" & Request.Form("ext_health") v_dent_cov = "" & Request.Form("dent_cov") v_emp_name = "" & Request.Form("emp_name") v_salary = "" & Request.Form("salary") v_sal_type = "" & Request.Form("sal_type") v_sex = "" & Request.Form("sex") v_dep_status = "" & Request.Form("dep_status") v_dob = "" & Request.Form("dob") v_prov = "" & Request.Form("prov") v_job_title = "" & Request.Form("job_title") v_job_class = "" & Request.Form("job_class") v_ehs = "" & Request.Form("ehs") v_dental = "" & Request.Form("dental") v_emp_date = "" & Request.Form("emp_date") v_cur_disabled = "" & Request.Form("cur_disabled") End If %>

news  • contact us        Group insurance taxation. Sponsored plans. Who our partners are. Dental Claim forms. Health Claim forms. Hospitality Plans - Request a quote.     Feel free to request a quote online or download and Acrobat version of our Quote Request Form and fax it in.  Note about eligibility:  Companies may participate in the program by insuring all full-time management employees who are eligible, without any waiting period.  Member companies may also choose to insure all full-time management and full-time employees who have completed three months service.  Management and employees must work an average of 25 hours per week to become eligible.   Please fill in the form below in it's entirety and submit it when you are finished.   COMPANY NAME:  ADDRESS:  CONTACT NAME:  TELEPHONE:    FAX:  TYPE OF BUSINESS:   # OF EMPLOYEES:  YEARS IN BUSINESS (minimum is 2 years):  IS THIS BUSINESS HOME BASED?  yeschecked<% End If %>>    nochecked<% End If %>> CHECK THE FOLLOWING BENEFITS CURRENTLY IN PLACE:  EICchecked<% End If %>>    CPPchecked<% End If %>>    WCBchecked<% End If %>> ARE YOU CURRENTLY PROVIDING A BENEFIT PLAN?  yeschecked<% End If %>>    nochecked<% End If %>> ARE YOU CURRENTLY PROVIDING GROUP RRSP?   yeschecked<% End If %>>     nochecked<% End If %>> If you have answered yes to any of the above please complete the following information: NAME OF INSURANCE COMPANY:  RENEWAL DATE (dd/mm/yy):     ©2003 Group Lockhart Inc. - 519.672.3890 or 1.800.265.1224