CES Enrollment – Competitive Benefits Administrators

If you have questions, please schedule a meeting at the link above prior to completing form.

Name *

First

Last

Gender *

Male
Female

Birth Date *

Address

City

State

Zip

Mobile Number *

Email *

AFLAC plans NOT Currently Enrolled but interested in: (Hold down the CTRL button to select multiple options) *

RETIREMENT PLANS NOT Currently Enrolled but interested in: (Hold down the CTRL button to select multiple options-Please schedule a meeting with CBA advisor) *

Please select if you would like to Enroll or if you would like a review of your current plan and a Financial Advisor will follow up with you.

Unreimbursed Medical Plan(FSA) 2021 limit $2750. Must be renewed every year. *

This is the medical reimbursement account. Not the Sec 125 cafeteria plan.

Dependent Care (FSA) 2021 limit $2500(filing single) $5000(filing joint) *

Section 125 Cafeteria Plan *

Elect (I wish to pre-tax all eligible benefits)
Decline

Dependent Names and Date of Birth (Please enter one per line/if not selecting coverage list N/A) *

Beneficiary Information for Accidental Death Benefit (Please enter Name, Date of Birth, Relationship and % - one person per line/if not selecting coverage list N/A) *

Do you use tobacco?

Has anyone to be covered had a heart attack, cancer, or stroke in the last 5 years?

Is anyone to be covered a Type 1 Diabetic?

Has anyone to be covered been hospitalized or had surgery in the last 12 months or have a future surgery planned?

Are you currently pregnant?

Does anyone to be covered have any chronic health conditions?

Phone