WorkingAmericanBenefits™

                                                                     
Product Selection:

       Life Insurance                                           Company                                   Amt. of Insurance

    Term Life Insurance              Select ALLIANZ Life Insurance Company Allstate Financial - AH Life Ins.Co. Colonial Supplemental Insurance Colorado Bankers Life Insurance Co. Illinois Mutual Life Insurance Company UnumProvident Life Insurance Co. Zurich Kemper - Federal Kemper Life Ins. Co.    

    Whole Life Insurance            Select ALLIANZ Life Insurance Company Colorado Bankers Life Insurance Co. Illinois Mutual Life Insurance Company UnumProvident Life Insurance Co. Zurich Kemper - Federal Kemper Life Ins. Co.    

    Universal Life Insurance          Select ALLIANZ Life Insurance Company Allstate Financial - AH Life Ins.Co. Colonial Supplemental Insurance Illinois Mutual Life Insurance Co. Texas Life Insurance Company UnumProvident Life Insurance Co. Zurich Kemper - Federal Kemper Life Ins. Co.    

    Variable Universal Life Ins.    Select ALLIANZ Life Insurance Company Zurich Kemper - Federal Kemper Life Ins. Co.    

       Health Insurance                                      Company                                   Deductible/CoIns.      Copay

    Major Med. PPO - 80/20         Select American Medical Security - Wisconsin Life Fortis Insurance Company Humana Insurance Company       Select $250 / $1000 $250 / $2000 $250 / $5000 $500 / $1000 $500 / $2000 $500 / $5000 $500 / $7500 $500 / $10000 $750 / $1000 $750 / $2000 $750 / $5000 $750 / $7500 $750 / $10000 $1000 / $1000 $1000 / $2000 $1000 / $5000 $1000 / $7500 $1000 / $10000 $1500 / $2500 $1500 / $3000 $1500 / $5000 $1500 / $7500 $1500 / $10000 $2500 / $5000 $2500 / $7500 $2500 / $10000 $5000 / $10000       Select $5 $7 $10 $15 $20 $25 $30 $35 $40

    Major Med. PPO - 70/30         Select American Medical Security - Wisconsin Life Fortis Insurance Company Humana Insurance Company       Select $250 / $1000 $250 / $2000 $250 / $5000 $500 / $1000 $500 / $2000 $500 / $5000 $750 / $1000 $750 / $2000 $750 / $5000 $1000 / $1000 $1000 / $2000 $1000 / $5000 $1000 / $10000 $1500 / $2500 $1500 / $5000 $1500 / $10000

    Major Med. PPO - 50/50          Select American Medical Security - Wisconsin Life Fortis Insurance Company Humana Insurance Company       Select $250 / $1000 $250 / $2000 $250 / $5000 $500 / $1000 $500 / $2000 $500 / $5000 $500 / $8000 $750 / $1000 $750 / $2000 $750 / $5000 $750 / $8000 $1000 / $1000 $1000 / $2000 $1000 / $5000 $1000 / $8000 $1000 / $10000 $1500 / $2500 $1500 / $3000 $1500 / $5000 $1500 / $8000 $1500 / $10000 $2500 / $5000 $2500 / $7500 $2500 / $8000 $2500 / $10000 $5000 / $8000 $5000 / $10000

    Major Med. PPO - 100/0         Select American Medical Security - Wisconsin Life       Select $500 / $0 $750 / $0 $1000 / $0 $1500 / $0 $2000 / $0 $2500 / $0 $5000 / $0 $7500 / $0 $10000 / $0 .............................

    Major Med. HMO                     Select Humana Insurance Company of Florida, Inc Vista Health Plan       Select None .............................

    Major Med. POS                    Select None ____________________________________.       Select None .............................

    Mini Med. HFP                       Select AmericanCare Health Flex Plan ____________________________________.       Select None .............................

       Gap/Bridge Ins.                                         Company                                  Amt. of Insurance

    Hospital Indemnity Ins.          Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance Fidelity Security Insurance Company       

       Dread Disease Ins.                                   Company                                   Amt./Plan of Ins.

    Cancer Insurance                  Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance ING - Relia Star Insurance Company       

    Critical Illness Insurance       Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance Colorado Bankers Life Insurance Co. Fort Dearborn Life Insurance Co. ING - Relia Star Insurance Company       

    Note: For Cancer coverage, enter the Plan of Insurance if the amount of insurance is not known.

       Disability Insurance                                  Company                                  Monthly Benefit

    Short Term Disability            Select Allstate Financial --- Amercan Heritage Life Colonial Supplemental Insurance Fort Dearborn Life Insurance Co. Illinois Mutual Life Insurance Co. ING - Relia Star Life Insurance Co. UnumProvident Life Insurance Co. Assurity Life Insurance Company Fidelity Security Life Insurance Co.       

    Long Term Disability          Select Fort Dearborn Life Insurance Company Illinois Mutual Life Insurance Company ING - Relia Star Life Insurance Company UnumProvident Life Insurance Company Assurity Life Insurance Company Fidelity Security Life Insurance Co. ____________________________________       

       Long Term Care Ins.                                Company                                 Daily Benefit Amt.

    Long Term Care                    Select ALLIANZ Life Insurance Company CNA Life Insurance Company GE Capital Assurance Company Great American Life Insurance Company John Hancock Life Insurance Company Kanawha Insurance Company Physicians Mutual Insurance Company State Life Insurance Company UnumProvident Life Insurance Company          

       Dental/Vision Plans                                  Company                                  Plan of Insurance

    Individual Dental Plan          Select FORTIS Insurance Company _______________________________                

    Group Dental Plan                Select American Medical Security Colorado Bankers Life Insurance Co. FORTIS Insurance Company Guardian Life Insurance Company                

    Individual Vision Plan            Select FORTIS Insurance Company _______________________________              

       Legal Insurance                                        Company                                  Plan of Insurance

    Individual Legal Plan            Select GUARDIAN Legal Services U.S. Legal Services, Inc. _______________________________                

Employee's Information: (Required)

First Name:       *          MI:            Last Name:*    

Street Address *     Apt. or Suite No.:     

City:                    *            State: *  - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code: * 

Social Security No.:*    Home Phone.: *    Work Phone: *

Enter the following ONLY if paying by List Billing or Payroll Deduction:

Employer/Co. Name:            Payroll Deduction?  Yes  No

Employer/Co. Address: 

Occupation/Duties:     Date Employed: Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31  

Hours Wrkd./Week:    Employee No.:    Annual Salary: 

Person to be insured Information

Note: Enter all that applies.

Proposed Insured: (Required)

First Name:       *          MI:            Last Name:*    

Street Address *     Apt. or Suite No.:     

City:                    *            State: *  - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY           Zip Code: * 

Relationship:    *  Select Self/Employee Spouse Dependent Other   Date Of Birth: * Month 01 02 03 04 05 06 07 08 09 10 11 12 Day 01 02 03 04 05 06 07 08 09 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Year 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1045 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920   Male   Female

Social Security No.:*   Height: ft ins    Weight: lbs.

Primary Beneficiary:   Age:   Relationship: Select All Children Equally Aunt Brother Cousin Daughter Father Fiance Friend Granddaughter Grandfather Grandmother Grandson Legal Dependent Mother Nephew Niece Sister Son Spouse Uncle Other

Contingent Bene.:      Age:   Relationship: Select All Children Equally Aunt Brother Cousin Daughter Father Fiance Friend Granddaughter Grandfather Grandmother Grandson Legal Dependent Mother Nephew Niece Sister Son Spouse Uncle Other

Medical History: (Required)

01.  Have you or any person to be insured used any form of tobacco, or any nicotine products

       in the last 12 months?                                                                                               Yes No

02.  To the best of your knowledge,  have you or any person to be insured ever tested

       positive for exposure to the HIV infection, or been diagnosed as having AIDS or ARC

       caused by the HIV infection, or sickness or condition derived from such infections?        Yes No

03.  To the best of your knowledge, have you or any person to be insured ever been

       treated for, or diagnosed with a chronic respiratory disorder, chest pain, stroke, heart

       attack, heart condition, cancer, or tumor?                                                                   Yes No

04.  Have you or any person to be insured ever had, been treated for, or diagnosed with

       any disorder of the heart, lymph glands, or immune system?                                        Yes No

05.  Have you or any person to be insured ever had, been treated for, or diagnosed with

       a) high blood pressure, diabetes, elevated cholesterol, fainting, seizure, alcoholism, or

           depression?                                                                                                          Yes No

       b) a cardiovascular, respiratory, digestive, liver, kidney, or blood disease or disorder?      Yes No

       c) a reproductive or urinary system disease or disorder?                                               Yes No

       d) a brain, mental, nerve or nervous disorder?                                                               Yes No

06.  In the past 3 years have you or any person to be insured:

       a) consulted a doctor, medical health professional, or mental health professional?           Yes No

       b) been hospitalized?                                                                                                 Yes No

       c) been advised to have any blood tests, electrocardiogram, or other tests or studies?     Yes No

07.  Have you or any person to be insured ever:

       a) used any illegal drugs?                                                                                           Yes No

       b) sought treatment or counseling, or been advised to quit, reduce, or seek treatment

           or counseling for alcohol or drug use?                                                                      Yes No

       c) attended or been advised to attend a drug or alcohol self-help group?                          Yes No

08.  Have you or any person to be insured been hospitalized or disabled within the last 6

       months?                                                                                                                    Yes No

09.  Have you or any person to be insured:

       a) currently under the care of a physician?                                                                    Yes No

       b) ever been rated or declined for life insurance?                                                            Yes No

       c) taking any medication?                                                                                               Yes No

10.  Have you or any person to be insured ever been treated for cancer or any malignancy

       which includes: carcinoma; sarcoma; Hodgkin's Disease; leukemia; lymphoma; or any

       malignant tumor?                                                                                                        Yes No

11.  Are you or any person applying for disability or life or health insurance actively at work

       now, and have worked at least 25 hours each week performing all duties at your or his/her

       regular occupation at your or his/her regular place of employment for the last 3 months

       except for minor illness or injury of 1 week or less, or normal pregnancy?                        Yes No

12.  Have you or any person to be insured, within the last 2 years, been treated for, or been

       told by a physician or member of the medical profession that you or he/she has diabetes,

       emphysema, asthma, epilepsy, hepatitis, mental or nervous illness, ulcers, any disorder

       of the central nervous system (including muscular dystrophy or multiple sclerosis); lupus;

       rheumatoid arthritis; fibromyalgia; chronic fatigue syndrome, or any disease or disorder of

       the heart, kidneys, liver, lungs or back?                                                                        Yes No

13.  Have you or any person to be insured engaged in, or contemplating engaging in: hang

       gliding; skydiving; underwater diving; organized racing events; rodeo; mountaineering;

       professional sports; or piloting an airplane?                                                                   Yes No

14.  Have you or any person to be insured, in the last 3 years, had your or his/her driver's

       license suspended or revoked or been arrested for reckless or drunken driving and/or

       received 3 or more moving violations or been involved in 3 or more accidents?                  Yes No

15.  Please list all medications you or any person to be insured take, the strength and the

       dosage of the medication in the space below.

16.  Please provide us with your doctor's name, address and telephone number.

Name:       Phone: 

Address:

17.  Driver's License Number    State:   - AL AK AZ AR CA CO CT DE DC FL GA HI ID IL IN IA KS KY LA ME MD MA MI MN MS MO MT NE NV NH NJ NM NY NC ND OH OK OR PA RI SC SD TN TX UT VT VA WA WV WI WY

Congratulations!  You have now completed your enrollment for insurance.  Please click on  the SUBMIT button below to submit your application for processing.   You will be contacted by a professional insurance agent/Enroller and/or Human Resource Department within the next 3 days to obtain your signature on the application as well as any additional information needed to complete the application.  If you are not contacted within the specified period, please contact us at (954)430-8475 or by e-mail at customer_service@workingamericanbenefits.com.