Your Name:

E-mail Address:

Company:

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:

Phone:

Product of Interest: 125 Legal Guide DataPath COBRA DataPath105 DataPath125 DataPath132 HSAToday i-Flex Max105 myResourceCard myRSC.com OMNI-Line ProDocs

Comments/Questions:

If you are interested in a particular DataPath product or service, filling out the following optional information will help us better analyze your needs:

Are you planning on administering benefits for:
Only the employees in my company
Employees of other companies
Neither

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

If you are a Plan Service Provider, please answer the following four questions (a-d):

a) For how many employers do you currently administer 125?
25 or less 26-100 101-150 151-250 251+

b) For how many total employees do you currently administer 125?
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

c) How many of the current employers for which you administer 125 are participating in an FSA benefit?
None 10% 11-25% 26-50% 51-75% 76-90% All

d) Current software being used to administer 125 plans, if applicable?

If you are an employer, please answer the following four questions (a-d):

a) How many employees do you have?
100 or Less 101-500 501-2,500 2,501-5,000 5000+

b) How many currently participate in your 125 plan?
POP:

FSA:

Full Flex:

c) How many locations does your company have?

d) Are you currently using another software package to administer your 125 plans?
No
Administration is outsourced
Yes

If yes, please name:

What type of benefits are you interested in administering? (choose all that apply)
FSA / Reimbursement Accounts
Section 132 Parking Reimbursement
Premium Only Plans (POP)
Eligibility/Enrollment for Traditional, Cafeteria and Credit-Based Plans
HIPAA
COBRA
Web-based Enrollment, Inquiry, and Self Service
IVR-based Enrollment and Inquiry

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 M6HUL9W3 here: