Benchmark Benefit Consulting, Inc.

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NOTE: Quotes for medical and dental
only provided for Georgia residents

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Type of Quote:	Life	Medical	Dental	Long Term Care
select all that apply	Cancer	Critical Illness	Key Employee
	Short Term Disability		Long Term Disability
Quote For:	Individual	Group
If for Individual:	Date of Birth:		Sex:
Number of Dependents to be covered:			Residence Zip Code:
If for Group:	Include below the following for each person to be covered (Name, Date of Birth/Age, Sex, Number of Dependents, Residence Zip Code, and Salary Amount)

If you would like to discuss retirement plan options, executive compensation structures,
buy/sell agreements, business succession planning, benefit tax implications/strategies,
or any other service, please feel free to contact us at (404) 346-0555 for a consultation.

Quote requests can be faxed to (404) 346-3957

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