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Quick
Print Quote Information Form
Please fax this document to (415) 454-2928
Please
enter the following information to allow us to develop a cost
estimate for your own self-funded dental plan. Be complete in
your responses so we may provide an accurate benefit plan for
your company.
These
(*) fields are required to submit quote requests.
*
Company Name ______________________________
*
Your Name ______________________________
*
Company Address ______________________________
*
E-mail ______________________________
Phone
Number ______________________________
Fax
Number ______________________________
I
prefer to be contacted by: E-mail ______ Phone ______ Fax _____
Nature
of Business ___________________________
Date
Plan renews _________________
*
Total number of employees _________________
*
Number of employees covered by dental plan ____________
*
Number of males _________________
*
Number of females _________________
*
Number of single employees _________________
*
Number of employees and 1 dependent _________________
*
Number of Families _________________
Job
classifications: (Enter percentage or 0 if not applicable).
*
Professional, Managerial:_____________ %
*
Clerical, Blue Collar: _____________ %
*
Educators: _____________ %
*
Employer pays _____________ % of employee premium
*
Employer pays _____________ % of dependent premium
*
Estimated annual employee turnover _____________ %
Current Plan features:
Type:
_____ indemnity _____ PPO _____ DMO _____ None
Annual
Maximum: _____ per person
or _______ per family
_______%
preventive _______% basic _______% major
_______%
orthodontics _______ deductible
Exclusions:
____________________________
*
What is your annual budget for dental benefits? ___________
What
would you like to change about your benefit plan?
_______________________________________________________
Please
fax the above document to (415) 454-2928
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