Get Your Group Dental Quote

Section 2
Please enter the company information:

	Company Name:
	Company Address:
	City:
	State:
	Zip Code:

Section 3
Additional company information:

		Where is the company's home office?
			City: State:
		Is this where the benefit buying decision is made?
		YesNo If "No", where is the decision made? City: State:
		What is the company's SIC Code?
			SIC Code:
		What is your estimate of the total employees and family members?
			Employees: Add'l Family Members:
		Does the company currently offer a dental benefit to its employees?
			YesNo
		If you answered "No" above, please skip to section 5.

Section 4
If you answered YES, then:

	Please indicate the type of plan currently offered: (check all that apply)
	Traditional indemnity Preferred Provider Dental HMO
	Is this a voluntary program or does the company pay all or part of the benefit?
	Voluntary Employer pays all Employer/Employee contribution
	When does the contract with the current carrier expire?
		Date:
	Who is the current carrier?
		Name:
	Why are you looking for a new dental benefits carrier? (check all that apply)
	Dissatisfied with service More plan options needed Company policy to re-bid Better cost/value Larger network needed Other
	How soon will you need a formal bid response?
		Date:

Section 5
If you answered NO, then:

	What type of dental benefits plan are you interested in?
	Traditional indemnity Preferred Provider Dental HMO
	How soon would you like the program in place?
		Date:
	How soon will you need a formal bid response?
		Date:

Section 6
Is there anything else you would like to tell us about the company?

Section 7
The Census
Please copy and paste the details of your employes or e-mail us the file.

Please provide the following information for each employee to be quoted in this group policy:
• First and Last Name of each person
• ZIP Code where the employee resides
• Birth Date and Gender
• Spouse/Children: whether the employee's spouse and/or children
should be included in the quote

First Name | Last Name | ZIP | DOB | Gender | Spouse | Children