Service Request Form

CRL Benefits Group LLC

"Building A Brighter Future For You and Your Employees"

Member

Houston AGC

Paper Blooms

Request a Quote:

1) Complete the excel census format or fill in the interactive census form and e-mail .

2) Complete the medical questionnaire.

3) E-mail the census to Chad@CRLBenefitsGroup.com

4) Fax medical questionnaire to 713-532-6613

5) Complete the On-line Request Form Below or fill in the interactive benefits form and e-mail.

Type of Request: Quote Information Meeting

PDF Attachments: If you have not already done so, you must have the current Adobe Acrobat Reader installed on your PC to the any attached adobe files. To download Acrobat Reader for FREE, visit the Adobe website at: http://www.adobe.com/prodindex/acrobat/readstep.html

Would you like to e-mail your census format Information ( in a spreadsheet format, excel, etc.) to us?

It must include the the following information: Company Name, Type of Business, Name of employees, Date-of-Birth, Sex, Zip code (required only if employees work in locations other than Corporate) and type of coverage (Employee, Spouse, Child(ren) and Family). Occupation and Salary must be included for Pension, Life multiples and LTD proposal requests. E-mail Attachments to:

Chad@CRLBenefitsGroup.com

Contact Information:

Name
Title
# of Employees
Company
Address
Telephone
FAX
E-mail

Medical Renewal Date: Current Medical Carrier:

Employee Benefits Currently Offered:

If you would like us to contact you at a later date please indicate date:

WHAT'S NEW

* * *

Free Individual

health quotes

(click on logos)

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Want to learn more about Health Care Savings Accounts?

Click Here

* * *

Open up an

ING Orange Savings account Today!

No Fees

No Minimums. FDIC Insured!

1.40% Annual Percentage Yield

(effective 07/03/2009)

Apply Today!

Open up an

ING Orange CD

or an

ING Orange Business Savings Account ! *

Call for current rates

* * *

Apply Online

Individual Medical

and Dental Online

Click on the icon below to enroll today!

* * *

Looking for Short Term Medical Coverage?

Apply Online Now!

* * *

Need International Medical Coverage?Apply Online

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Savings for your child's college education?

Start saving early for your child's education by investing in a College 529 Savings Plan.

Look under investment services for more details.

* * *

Are you a small business looking to put in a 401(k) or retirement plan for your employees.

See Investment services for details.

*Securities and Investment Advisory Services offered through Financial Network Investment

Corporation, Member SIPC, Member of ING Advisors Network.

Financial Network Branch address:1900 St. James Place, Suite 400, Houston, TX 77056 713-785-3404

CRL Benefits Group LLC and Financial Network are not affiliated companies.

Investment products and services available only to residents of Colorado (CO), Texas (TX).

**Fee-based investment advisory services available only to residents of Colorado (CO), Texas (TX)

Independent Sales Agent, Not an employee of ING Bank fsb. ING Orange Savings Account APY may change at any time based upon market conditions, 6/02/04.