Select any of the following plans that you would be interested in:                                                                                 Individual Dental 
Employee Paid -- Voluntary Vision                                Employer Contributed Dental                                     Employee Paid -- Voluntary Dental
Employer Contributed Vision                                         Employee Paid -- Voluntary Short Term Disability  Employer Contributed Short Term Disability
Employee Paid -- Voluntary Long Term Disability      Employer Contributed Long Term Disability           Employee Paid -- Voluntary Life Insurance
Employer Contributed Life Insurance                           Employer Contributed Medical Health Insurance

If you have a current dental plan, how many of the following participate? Individual's participate:                  Individual Plus One:                       Full Family's:                                    Please provide the following contact information: Name Title Organization Street Address Address (cont.) City State/Province Zip/Postal Code Work Phone FAX E-mail URL DMS DENTAL Copyright © 2001 [DMS DENTAL]. All rights reserved. Revised: January 11, 2002