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Group Quote Request

Please fill out the following form to request a group quote by fax, e-mail or mail.

(* indicates required field)

COMPANY INFO
  see privacy policy
Company Name*
Type of Business*
Contact Name*
Address*
 
City*
State*
Note: Plans are for California only
Zip*
Phone*
Fax
E-mail*
Do you prefer to receive quote by: Fax
E-mail
US mail
Comments:

 

CURRENT PLANS (if any)
Current Carrier
Current Rates
Why changing?
Group medical coverage in place? Yes No

 

EMPLOYER CONTRIBUTION
Employer will contribute what % of premium cost for eligilbe employees?

 % for employees
Employer will contribute what % of premium cost for eligible employee's dependents?

 % for dependents

 

TYPE OF PLAN
Type of plan desired (if known).
Indemnity or PPO:
More Expensive
Any Dentist		 DHMO:
Less Expensive
List of Dentists
 

Estimated Effective Date

 

EMPLOYEE INFORMATION
Number of eligible employees*
Number of eligible dependents*
Eligible employees work hours/week.

 

EMPLOYEE CENSUS DATA
 
This section is optional, but it helps us give you a more accurate quote. Final rates are based on the actual enrollment. You can fax or mail this information in your own report format if that is more convenient.


Employee Name or Initials

Age or DOB

Male or Female

Married or Single

No. of Dependent Children

ex. John Doe 10/10/65 Male Married 1
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