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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