1.Your name

2.Company Name

3.Email

4.Are you interested in learning more about a benefits plan through the AFCC?

Yes

No

Maybe

5.How many employees at your company?

6.What is the avg. age of your company's employees? (an estimate is fine)

17 or younger

18-20

21-29

30-39

40-49

50-59

60 or older

7.Additional Questions?