EMPLOYERS
EMPLOYER TOOLS
Here are a few tools that should be helpful.
Employer Forms
Order Brochures
Request a Quote
FAQs
A Glossary of terms
Your Benefit Summary
Request Quote Form
Contact Information
Date Quote Submitted:
Date Quote Requested Back:
Group Name:
Organization:
Street Address:
Address (cont.):
City:
State/Province:
Zip Code:
Country:
Work Phone:
Fax:
E-mail:
Program Information
Do you currently offer a dental plan to your employees?
Yes
No (
Skip to Demographic Information
)
Name of Current Dental Carrier:
Date that Dental Plan began:
Description of Current Benefit Program:
Risk
Self-Insured
Type of Service
Covered Percentage
Preventative/Diagnostic
%
Restoration/Surgeries
%
Periodontal
%
Crowns
%
Dentures/Bridges
%
Orthodontal
%
Deductible:
$
Maximum Benefits:
$
per person per covered year/Non-Orthodontic
$
per Lifetime/Orthodontic
Current Rates
Single:
Dependent:
Employee+1:
Family:
Total Family:
Will employee contributions be required?
Yes (please indicate below how costs will be divided)
No
Employee coverage:
Employee pays:
%
Employer pays:
%
Dependent coverage
Employee pays:
%
Employer pays:
%
Demographic Information
Date you wish to implement Dental Benefit Program:
Total Number of Employees:
Single Coverage:
Family Coverage:
Estimated Annual Turnover Rate:
Employee Class Data
A. Executive, Sales, Professional, Managerial:
B. Clerical:
C. Labor:
Employee Gender Data:
Male
Female
Dependent Children to Age 19, Students to what age:
Is Participation contingent on participation in the Medical Benefits Program?
Yes
No
Are Experience (Loss Ratio Reports) Available?
Yes
No
Are you currently working with a broker/agent?
Yes
No
If yes:
Name:
Phone:
Comments:
Submitted By:
Name:
Title:
Verification:
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