Name:

E-mail:

Company:

Phone:

Website:

Address 1:

Address 2:

City:

State: Alabama Alaska Arizona Arkansas California Colorado Connecticut District of Columbia Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming    Zip Code:

Area(s) of Interest (select at least one):

Comments/Questions:

Are you currently administering in-house or do you outsource?
In-house Outsource

Which best describes your type of organization?
Accountancy Firm Actuarial Service Bank or Trust Department Benefits Consultant Broker Fee-Based 125 Plan Service Provider Group Health Insurance Agency Health TPA Law Firm Life Insurance and Annuity Agency Property and Casualty Insurance Agency Supplemental Insurance Agency Retirement TPA Other

For how many employers do you currently administer?
25 or less 26-100 101-150 151-250 251+

For how many total participants do you currently administer?
1,000 or less 1,001-2,500 2,501-5,000 5,001-7,500 7,501-10,000 10,001-15,000 15,001-25,000 25,001-40,000

Current software being used to administer, if applicable?

How did you hear about DataPath?
Referral Magazine ad or listing Trade show Web search Web ad or listing Other

When do you plan to install a new benefits system:
Within the next 3 months 3-6 months 6-12 months Probably never / You're a consultant gathering info

* Enter this Confirmation Key 1h930n4a here: