INSERVE Corporation 11201 SE Eighth Street, Suite 190 Bellevue, WA 98004 Map and Directions Telephone: (425) 646-4400 (800) 676-3433 Fax: (425) 453-7889 E-mail: info@in-serve.com The following will assist us in providing information pertinent to your company interests. The data you provide is considered confidential and will be treated as such. Name:   Title:   Company:   Address:   |   City:   State/Province:   _ Zip/Postal Code: Work Phone:   Fax:   E-mail:   Web Site:   Number of Employees:   Number of Years In Business:   Select any of the following benefits currently being offered: Health Dental LTD 401k Plan Voluntary Benefits Vision Life STD Section 125 Questions/Comments: _______