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 BENEFITS ADMINISTRATION

 

  

Interested in a Quote?  Please use the following form for a quick response.  Thank you.

Group/Company Name
Contact
Address
City
State Zip
E-mail
Phone Fax
Do you currently provide
employees a dental plan?		 YES NO
If Yes, What Dental Company? HMO
PPO
Indemnity
Self-Insured
Date plan began # of Tiers in Current Plan
(1, 2, 3, 4)
Current Rates for Current Plan Employee Only $
Employee + Child $
Employee + Spouse $
Employee + Family $
Effective Date for DR Proposal
Current Data # of Employee Only
# of Employee + Child
# of Employee + Spouse
# of Employee + Family
# Total
Percent of Eligible Employees Enrolling %
Percent of Eligible Dependents Enrolling %
Percent of Employee Contribution Paid By Employer %
Percent of Dependent Contribution Paid By Employer %
100% of First $50,  50% of next $300, Maximum Annual Benefit =$200
100% of First $150, 80% of next $700, Maximum Annual Benefit =$500
100% of First $100, 80% of next $500, 50% of next $500, Maximum Annual Benefit =$750
100% of First $100, 80% of next $250, 50% of next $1400, Maximum Annual Benefit =$1000
100% of First $200, 80% of next $500, 50% of next $800, Maximum Annual Benefit =$1000
100% of First $300, 80% of next $750, 50% of next $600, Maximum Annual Benefit =$1200
100% of First $500, 50% of next $3000, Maximum Annual Benefit =$2000
100% of First $250, 80% of next $750, 50% of next $1300, Maximum Annual Benefit =$1500
100% of First $500, 80% of next $500, 50% of $500, Maximum Annual Benefit =$750
Create your own plan...
% of $, % of $, % of $, Maximum Annual Benefit = $

 

 

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