May Insurance Services, Inc.

"Service" is more than just our name

Fort Dearborn Life
(see table below as to which applications to use)
www.fdl-life.com

Application Employee Basic/Voluntary Z5220 2/07
Application Employer Basic Z6183 1/07
Application Employee PPO Dental 4-Tier and Voluntary PPO Dental Z6209 5/06
Application Employer PPO Dental 4-Tier Z6185 4/05
Application Employee Scheduled Indemnity Dental Z6058 1/05
Application Employer Scheduled Indemnity Dental Z6008 1/05
Application Employer Voluntary PPO Dental Z6185v 5/05
Application Employer Voluntary Z619712/07
Beneficiary Form X6053 2/07
Benefits Managers Registration BMRA 7/07
Dental Brochure (group) 05218 9/05
Dental Network
Evidence of Insurability (EOI) Form Z4306 11/07
Life Brochure (group) 2/05
Long Term Disability (LTD - Group) Flyer 0518 10/05
Short Term Disability (STD - Group) Flyer 10/05
Voluntary Critical Illness Flyer 2/05
Voluntary Dental (group) Brochure 9/05
Voluntary Dental Flyer 2/05
Voluntary Life (group) Flyer 2/05
Voluntary Long Term Disability (LTD - group - less than 50) Flyer 3/06
Voluntary Long Term Disability (LTD - group - 50+) Flyer 3/06
Voluntary Short Term Disability (STD - group) Flyer 2/05

PRODUCT	EMPLOYER APPLICATION	EMPLOYEE APPLICATION
Basic Coverages 10+ lives Life/ADD STD LTD	Z6183	Z5220
Voluntary Coverages 2+ lives Life/ADD STD LTD Dental Critical Illness	Z6197	Z5220
Basic PPO Dental 4-Tier 10+ lives	Z6185 (includes BMRA )	Z6209
Voluntary PPO Dental 10+ lives	Z6185v (includes BMRA )	Z6209
Voluntary Scheduled Indemnity Dental 2-9 lives	Z6008	Z6058

May Insurance Services, Inc. is a BrokerNet, Inc. affiliate.