Additional Benefits information overview
Use this form to request information related to any Flexbene or M.A. Services product or service.

General Information    (* = required)
Name:*	Email:*
Employer:	Date Employed:
Address:	Phone:*
Social Security #:	DOB:*
Occupation:*	Current Annual Salary:*
Smoker?* Y  N
Work more than 30 hours per week at current job?*
	Y  N
LIFE INSURANCE (find out how much you need!)
Iinterested in Life Insurance value of:  ($50,000 minimum)
TERM or UNIVERSAL LIFE? 10 Year Term 15 Year Term 20 Year Term UNIVERSAL LIFE
LONG TERM CARE
Interested in Long Term Care
DISABILITY INCOME COVERAGE
Elimination Period 30 Day 90 Day 180 Day	Benefit Duration 5 Years Age 65
OTHER BENEFITS
Annuities IRA's Mutual Funds (select multiple options by: Ctrl-left mouse click)
comments/questions
Questions?? > > Don't hesitate to call us at (585) 538-9440 x3007 or (800) 836-8100