CES Enrollment CES Aflac Brochure Rates (optimized) FSA Healthcare FSA Dependent CareSchedule a meeting with one of our representatives If you have questions, please schedule a meeting at the link above prior to completing form. Please enable JavaScript in your browser to complete this form.Name *FirstLastGender *MaleFemaleBirth Date *AddressCityStateZipMobile Number *Email *AFLAC plans NOT Currently Enrolled but interested in: (Hold down the CTRL button to select multiple options) *AccidentCancerShort Term DisabilityLife InsuranceSpecified EventHospital IndemnityDecline all Aflac CoveragesContinue all 2019 existing coverageRETIREMENT PLANS NOT Currently Enrolled but interested in: (Hold down the CTRL button to select multiple options-Please schedule a meeting with CBA advisor) *403b/457bDecline all Retirement Plan CoveragesContinue with existing coveragePlease 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. *Yes (Enroll Me)No (Decline)This is the medical reimbursement account. Not the Sec 125 cafeteria plan.Dependent Care (FSA) 2021 limit $2500(filing single) $5000(filing joint) *Yes (Enroll Me)No (Decline)Section 125 Cafeteria Plan *Elect (I wish to pre-tax all eligible benefits)DeclineDependent 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?NoYesHas anyone to be covered had a heart attack, cancer, or stroke in the last 5 years?NoYesIs anyone to be covered a Type 1 Diabetic?NoYesHas anyone to be covered been hospitalized or had surgery in the last 12 months or have a future surgery planned?NoYesAre you currently pregnant?NoYesDoes anyone to be covered have any chronic health conditions?NoYesCommentSubmit