Please complete and submit the following form to Comprehensive Benefit Services, Inc.

Current Life/AD&D Company
Renewal Date:
Amount of Current Life Benefit:	Flat $
1 x earnings to a max. of	$ Other
Current Life/AD&D Rates:	Life     $ AD&D     $
Current Health Plan Company:
Renewal Date
Type of Current Plan:	HMO POS PPO
Current Health Plan Monthly Rates:	Single  $ Employee + Spouse  $ Employee + 1 Child  $ Employee + Children  $ Family  $
Current Dental Plan Company:
Renewal Date:
Type of Dental Plan:	Traditional Discount
If Traditional, amt. of annual maximum $ Deductible $
Dental Plan Design:	% Basic % Major % Ortho
Is Orthodontia covered?	No Yes:
If so, whom does the orthodontia cover?: Children Only Adults & Children
Orthodontia Max.	$
Current Dental Monthly Rates:	Single  $ Employee + Spouse  $ Employee + 1 Child  $ Employee + Children  $ Family  $
Current Short-Term Disability (STD) Company:
Length of Time with Current Company:
Current STD Waiting Period	Accident   days Sickness days
Current STD Plan Benefit Period:	13 weeks 26 weeks
Current STD Plan Renewal Date:
Current STD Rates:	$ per $10
Current Amt. of STD Benefit:	% of earnings to a max of $ per week.
Current Long-Term Disability (LTD) Company:
Length of Time with Current Company:
Current LTD Waiting Period	Accident   days Sickness days
Current LTD Plan Benefit Period:
Current LTD Plan Renewal Date:
Current Amt. of LTD Benefit:	% of earnings to a max. of $ per month.
Current LTD Plan Rates:	$ per $100

Any other questions or comments: