Employee Benefit Advisors Services

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Your Federal Employee Benefits Analysis

Do You Have Questions? Call Us Toll-Free 1-877-688-5505

Complete the Questionnaire fully and accurately. Please don't hesitate to call us for help.

PERSONAL INFORMATION

Your Name:
Date of Birth:	\| \|
Your Age:
Spouse's Name:
Date of Birth:	\| \|
Spouse's Age:
Home Address:
City:
State:
Zip:
Home Phone:
Cell Phone:
Home Fax:
Email Address:
Employer:
Job Title:
Work Address:
Work City:
Work State:
Work Zip:
Work Phone:
Work Fax:
Best Time to Contact: AM PM
Gender: Male Female
Number of Dependent Children (under18):
Child(ren) Ages: \| \| \|

EMPLOYMENT INFORMATION

Service Computation Date:	\| \|
Date of Hire :	\| \|
Date of Retirement:	\| \|
Retirement Age:
Date of Retirement:	\| \|
Retirement Age:
Retirement System:	CSRS FERS Offset Transfer
If Transfer (under new FERS, after transfering from CSRS, what is the date of transfer and the amount of sick leave at the time of transfer?) Date: \| \| and Hours
Retirement Type:	Regular ATC LE FF Other
If special duty then specify the start date as an ATC/LE/FF. Date: \| \|
Current Pay Grade:
Step:
Locality:
Expected Annual Salary Increase:	%
Current Annual Salary w/Locality:
Annual Salary 1 Year Prior:
Annual Salary 2 Years Prior:

MILITARY SERVICE INFORMATION

Active Duty:
Date of Enlistment:	\| \|
Date of Separation :	\| \|
Have you bought-back your miltary time? Yes No

IF A SPECIAL SITUATION EXISTS, PLEASE PROVIDE DETAILS IN THE COMMENTS BOX AT THE END OF THIS FORM (PART-TIME SERVICE, BREAKS IN SERVICE, ETC.

1) Have you at any time quit the Federal Government or had temporary service? Yes No

2) If yes, have you already processed either the SF-2803 (CSRS) or the SF-3108 (FERS) to request the necessary deposit or re-deposit information? If yes, please provide us a copy of OPM's response. If no, contact one of our analysts at 1-877-688-5505.

RETIREMENT INFORMATION

Federal Employee's Health Benefits (FEHB) Bi-weekly Cost:
CSRS Sick Leave Hours to be Save Each Pay Period (hours - bi-weekly):	0 1 2 3 4
CSRS Sick Leave Saved to Date (hours):
Monthly Social Security Benefit at Age 62:

SPOUSE'S SURVIVOR BENEFIT PLAN (SBP)

Select the desired amount of Survivor's Benefit
CSRS Survivor Benefit Plan: (100% to 0%)	%
FERS Survivor Benefit Plan:	50% 25% 0%

FEDERAL EMPLOYEE'S GROUP LIFE INSURANCE (FEGLI)

FEGLI Coverage (check all that apply):	None Basic Option A (Standard Coverage) - $10,000
Option B (Optional Coverage) Multiply of Basic Pay rounded to the next $1,000: 1 2 3 4 5 Times
Option C (Family Coverage) Multiply of $5,000 for your spouse and $2,500 each eligible child: 1 2 3 4 5 Times
FEGLI Bi-weekly Total Cost:
Basic:
Option A :
Option B:
Option C:

THRIFT SAVINGS PLAN (TSP)

Do you participate in TSP?	Yes No
Bi-weekly Contribution:	or %
Total Balance:
Catch-up Contribution:	or %

General Funds	C Fund	F Fund	G Fund	I Fund	S Fund
Current Balance ($)
Contribution Allocation (%)

L-Series Funds	L Income	L 2010	L 2020	L 2030	L 2040
Current Balance ($)
Contribution Allocation (%)

When do you plan to take distribution?	Age
How do you plan to distribute?	Lump Sum Monthly

COMMENTS

Please use this section to explain any special situations.