Dental Insurance Proposal Request Form

First Name: City
Last Name: State
Company: Zip
Street Address 1: Phone#:
Street Address 2: Fax#:
    E-Mail:
Group Name:      
Nature of Business:    
County: 
State:
Zip Code: 
Requested Effective Date:    

Do the employees contribute towards the cost of health insurance?

 Number of employees in Company:

Number of employees participating in health plan: 

    
Census:      
Employee: EE & Spouse: 
EE & 1 Child: EE & Children:
Full Family:     
Location of Employees: Suffolk, Nassau, Queens NY State
  Tri-State Other
If other (please give City,
State and Zip Code of employees):
Type of Plans to be Quoted:  DMO DUAL OPTION INDEMNITY
UCR Level:   70% 80% 90%    
Deductible:
Current Plan:
Carrier, Deductible, Co-Insurance, Details Of Coverage
Current Rates:
Single: EE/SP: EE/1 Child:
EE/Children: Full Families:   
Renewal Date:  
What is the client trying to accomplish: 
 Does not like current carrier   
  Lower Cost
  Improve Benefits
   
 
Please add any suggestions or comments which might be helpful.
Do you wish your proposal sent to you by:  Mail Fax Phone  

                                       
 
 
 
 
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