Western Benefit Planners Insurance Services, LLC

545 East 4500 South, Suite #E-250 * Salt Lake City, UT 84107 * (801) 288-9700 * Fax: (801) 288-9783

EMPLOYER: PHONE #: 801-

ADDRESS: FAX #: 801-

NATURE OF BUSINESS: AGENT:

NAME AND / OR CODE	DATE BORN			SEX		EE	DEP STATUS			EARNINGS		OCCUPATION, TITLE, CLASSIFICATIONS	DATE EMP
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DEPENDENT STATUS CODES : EE = EMPLOYEE ONLY S = SPOUSE ONLY C = CHILD(REN) ONLY FA = FAMILY