Stier Financial

Phone: (403) 571-6020

Toll Free: 1-800-267-9606

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Dealing Representative of

Stier Financial Group Inc.

Suite 201, 10820 24^th Street SE
Calgary, Alberta, Canada
T2Z 4C9

Phone:(403) 571-6020
Toll Free: 1-800-267-9606

Request to Quote for Employee Benefits

Please fill out this form and submit it to our offices to request a free quote for employee benefits.
(*) signifies mandatory fields which must be completed prior to submission of the form.

Health Information

Are any employees disabled, or not actively at work? (*)	YesNo Required information
Do you have any reason to believe that any of the employees and/or their dependants are not healthy? (*)	YesNo Required field

Employer Contribution Information

What percentage of these benefits will the company pay on a percentage bases?

Benefit	Employer %
Life	Please enter a numeric value for the Life benefit percentage the employer will pay
AD & D	Please enter a numeric value for the AD & D benefit percentage the employer will pay
W.I.	Please enter a numeric value for the W.I. benefit percentage the employer will pay
LTD	Please enter a numeric value for the LTD benefit percentage the employer will pay
Health	Please enter a numeric value for the Health benefit percentage the employer will pay
Dental	Please enter a numeric value for the Dental benefit percentage the employer will pay
Other	Please enter a numeric value for the Other benefit percentage the employer will pay

Class Information

Companies may choose to offer different packages to groups of employees within the company. For example, the "management team" may have a higher coverage than "general staff".

The term "management team" and "general staff" are simply names for classes of coverage. Below you will find two fields called class A and class B. You can place a descriptive name beside each class if you are defining more than one. If you are only interested in one package then simply fill out the class A information below. If you are wanting two packages, then continue and fill out class B also and select different coverage.

Class A Definition Name	Invalid Input
Class B Definition Name	Invalid Input

Class A Plan Design Information
Group Life & Accidental Death & Dismemberment

Group Life & Accidental Death & Dismemberment Amount (*)

Please complete group life & accidental death & dismemberment

Please enter a number

Dependent Life Insurance

Dependent Life Insurance (*)

$5,000 spouse / $2,500 child
$10,000 spouse / $5,000 child

Please select amount for dependent life insurance

Weekly Indemnity

Weekly Indemnity	Not Required Invalid Input
Taxable	YesNo Invalid Input
Percentage of Wage	60%66.67%graded Invalid Input
Day Accident	Invalid Input
Day Sickness	Invalid Input
(# weeks) Benefit Period	Invalid Input
Weekly Maximum	Invalid Input
First Day Hospital	YesNo Invalid Input

Long Term Disability

Long Term Disability	Not Required Invalid Input
Taxable	YesNo Invalid Input
Percentage of Wage	60%66.67%graded Invalid Input
Starts after	17 weeks26 weeks Invalid Input
Pays for	2 years5 yearsto age 65 Invalid Input
maximum monthly benefit	Invalid Input
non-evidence maximum	Invalid Input
Occupation	2 year own occany occ to age 65 Invalid Input

Extended Health Care

Extended Health Care	Not Required Invalid Input
Taxable	YesNo Invalid Input
Co-Insurance	80%80% Drugs/100% other100% Invalid Input
Annual Deductible	Nil$25/$25$25/$50$50/$50$50/$100 Invalid Input
Dispensing Fee Deductible	Invalid Input
Paramedic Practitioners	Invalid Input
Pay Direct Drug Card?	YesNo Invalid Input
Out of Country?	YesNo Invalid Input
Survivor Benefit?	YesNo Invalid Input

Vision Care

Vision Care	Not Required Invalid Input
Include Exams?	YesNo Invalid Input
Maximum amount per 24 months	Invalid Input

Dental Care

Dental Care	Not Required Invalid Input
Annual Deductible	Nil$25/$25$25/$50$50/$50$50/$100 Invalid Input

Basic Reimbursement

Basic:	100%80% Invalid Input
Major:	Nil50% Invalid Input
Orthodontia	Nil50% Invalid Input

Annual Maximums

Basic:	Unlimited$1,000$1,500 Invalid Input
Major:	$1,000$1,500$2,000 Invalid Input
Combined	$1,000$1,500$2,000 Invalid Input

Lifetime Maximum - Orthodontia

Lifetime Maximum - Orthodontia

$1,000$1,500$2,000

Invalid Input

Class B Plan Design Information
Group Life & Accidental Death & Dismemberment

Group Life & Accidental Death & Dismemberment Amount

Invalid Input

Please enter a number

Dependent Life Insurance

$5,000 spouse / $2,500 child
$10,000 spouse / $5,000 child

Invalid Input

Weekly Indemnity

Weekly Indemnity	Not Required Invalid Input
Taxable	YesNo Invalid Input
Percentage of Wage	60%66.67%graded Invalid Input
Day Accident	Invalid Input
Day Sickness	Invalid Input
(# weeks) Benefit Period	Invalid Input
Weekly Maximum	Invalid Input
First Day Hospital	YesNo Invalid Input

Long Term Disability

Long Term Disability	Not Required Invalid Input
Taxable	YesNo Invalid Input
Percentage of Wage	60%66.67%graded Invalid Input
Starts after	17 weeks26 weeks Invalid Input
Pays for	2 years5 yearsto age 65 Invalid Input
maximum monthly benefit	Invalid Input
non-evidence maximum	Invalid Input
Occ	2 year own occany occ to age 65 Invalid Input

Extended Health Care

Extended Health Care	Not Required Invalid Input
Taxable	YesNo Invalid Input
Co-Insurance	80%80% Drugs/100% other100% Invalid Input
Annual Deductible	Nil$25/$25$25/$50$50/$50$50/$100 Invalid Input
Dispensing Fee Deductible	Invalid Input
Paramedic Practitioners	Invalid Input
Pay Direct Drug Card?	YesNo Invalid Input
Out of Country?	YesNo Invalid Input
Survivor Benefit?	YesNo Invalid Input

Vision Care

Vision Care	Not Required Invalid Input
Include Exams?	YesNo Invalid Input
Maximum amount per 24 months	Invalid Input

Dental Care

Dental Care	Not Required Invalid Input
Annual Deductible	Nil$25/$25$25/$50$50/$50$50/$100 Invalid Input

Basic Reimbursement

Basic:	100%80% Invalid Input
Major:	Nil50% Invalid Input
Orthodontia	Nil50% Invalid Input

Annual Maximums

Basic:	Unlimited$1,000$1,500 Invalid Input
Major:	$1,000$1,500$2,000 Invalid Input
Combined	$1,000$1,500$2,000 Invalid Input

Lifetime Maximum - Orthodontia

Lifetime Maximum - Orthodontia

$1,000$1,500$2,000

Invalid Input

Employee Data

	Employee's Name	Occupation	Date of Birth (mm.dd.yyyy)	Salary	Coverage	Prov	Class
1.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
2.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
3.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
4.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
5.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
6.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
7.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
8.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
9.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
10.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
11.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
12.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
13.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
14.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
15.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
16.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
17.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
18.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input
19.	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input	Invalid Input

Comments, Questions, or Details	Invalid Input

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Insurance Services

Group Health and Dental

Employee Benefits Quote

This site is not intended to solicit the purchase of a security, full details are provided by offering memorandum. Past performance is no guarantee of future performance.

Company Name (*)	Please enter the company name
Nature of Business (*)	Please provide us with the nature of your business
Years in Business (*)	Please enter a number for years in business
Company Address (*)	Please provide the address of the company
City (*)	Please input City
Province (*)	Please select a Province
Phone (*)	Please provide phone number
Fax (*)	Please enter fax number
Contact Person (*)	Please provide the name of the person to be contacted
Email (*)	Please provide email address
Website (*)	Please provide companies website
Present Carrier (*)	Please provide the name of your present insurance carrier
Effective Date (mm.dd.yyyy) (*)	Please enter the effective date mm.dd.yyyy
Renewal Date (mm.dd.yyyy) (*)	Please enter the renewal Date mm.dd.yyyy

Stier Financial

Main Menu

Company Information

Health Information

Employer Contribution Information

Class Information

Class A Plan Design Information Group Life & Accidental Death & Dismemberment

Dependent Life Insurance

Weekly Indemnity

Long Term Disability

Extended Health Care

Vision Care

Dental Care

Class B Plan Design Information Group Life & Accidental Death & Dismemberment

Dependent Life Insurance

Weekly Indemnity

Long Term Disability

Extended Health Care

Vision Care

Dental Care

Employee Data

Class A Plan Design Information
Group Life & Accidental Death & Dismemberment

Class B Plan Design Information
Group Life & Accidental Death & Dismemberment