CAFETERIA PLAN PROPOSAL REQUEST FORM

Print, complete and fax to:

FLEXIBLE BENEFIT GROUP, INC.    

ATTN: Kevin Whitney

FAX: 972 991 5155

Company Information:

Official Company Name: _______________________________________

Street Address ______________________________________________

City, State, ZIP ______________________________________________

Contact Name ______________________________________________

Telephone ____________________ Fax __________________________

Any related or subsidiary companies? ____________________________

Plan Information:

New Plan _____ Takeover Plan _____ Start date of Plan Year __________

Number of eligible employees ________________

Number of excluded employees ____________Why__________________

Plan to include:

Eligible Premiums____________

Medical Spending Account _____ Maximum Salary Reduction $_________

Dependent Care  ____________  Maximum  Salary Reduction $_________

Proposal to be delivered by: W. Forrest Veal, CLU

                                                       Veal Benefit Services Inc.

                                                        Tel. 972 250 6516

RFP/VBS