Benefits Selling Free Subscription

	*Benefits Selling* is free to qualified professionals. Summary Description
	To apply for a FREE subscription to *Benefits Selling*, please answer ALL of the questions on the form below.
	The magazine publisher determines qualification and reserves the right to limit the number of free subscriptions.
	Geographic Eligibility: USA

1.	*Do you wish to receive a FREE subscription to Benefits Selling?*

Yes No

First Name:
Last Name:
Job Title:
	(Ex: Director, Vice President, Project Manager, etc.)
Company Name:
	(Please provide your Company Name in full: abbreviations could disqualify you)
Address:
Division/Department:
City:
State/Province:
Zip/Postal Code:
Country:
	(Note: If your country is not listed above, subscriptions are not currently available at your location.)
Phone:
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Email:
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Which of the following best describes your industry? (select only one)

Please specify for Other:

What is the approximate number of employees in your company? (select only one)

Yes, please auto-fill my contact information for other publication qualification forms.

2.	I recommend, specify or sell: group and/or voluntary benefits, retirement plans, or consumer-driven healthcare products.

Yes No

3.	The following best describes my Title: (select only one)

Advisor Consultant

Agent Planner

Broker Other

4.	The markets my firm currently/plans to target include: (select all that apply)

Small Business Market Government Market

Large Business Market Bank Market

Association Market Other

5.	My firm works with groups of the following sizes: (select all that apply)

100 lives and under 1,001 to 5,000 lives

101 to 1,000 lives 5,001 or more lives

6.	My firm offers the following products/services: (select all that apply)

Voluntary Benefits (LTCI, Auto, Home, Legal, Gap, Accident, Cancer, Discount) Retirement Savings Plans (401K, Deferred Compensation)

Core Benefits (Basic Life, Disability, Medical, Flexible Spending) Worksite Marketing/Enrollment

Health Benefits (Medical, Dental, Vision, Flexible Spending) Risk Management/Asset Protection

Life Benefits (Basic Life, AD&D, Voluntary Life, Travel Accident) Executive/Key Person Benefits

Disability Benefits (Short Term, Long Term, Individual DI) Business Liability, Property, Commercial Insurance

Group P&C (Auto, Homeowners, etc.) None of the Above

Payroll Deduction Services

7.	My Income is: (select only one)

$25,000 - $64,999 $150,000 - $199,999

$65,000 - $99,999 $200,000 - $299,999

$100,000 - $149,999 Over $300,000

8.	I have been involved in selling for: (select only one)

1-3 Years 16-20 Years

4-10 Years 21+ Years

11-15 Years Not involved in selling

9.	I am: (select only one)

Independent Semi-Captive Captive

10.

What month were you born?

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