Group Dental Insurance
Firstname * Lastname * Dental coverage, or more correctly a dental benefits plan, reimburses you for certain dental expenses according to written agreement. Dental benefits usually are provided under a contract between your employer or union (the plan's "sponsor") and an insurance company, sometimes referred to as a third-party carrier. There are several types of dental insurance and fall into these categories: Indemnity Plans, PPO's, Dental HMO's and Discount Referral Plans. Policyholder Name Occupation Current Employer Street Address City * State * AlaskaAlabamaArkansasArizonaCaliforniaColoradoConnecticutDist of ColumbiaDelawareFloridaGeorgiaHawaiiIowaIdahoIllinoisIndianaKansasKentuckyLouisianaMassachusettsMarylandMaineMichiganMinnesotaMissouriMississippiMontanaNorth CarolinaNorth DakotaNebraskaNew HampshireNew JerseyNew MexicoNevadaNew YorkOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVirginiaVermontWashingtonWisconsinWest VirginiaWyoming ZIP Code * E-Mail * Phone * Fax Effective Date * / / Plan Design * HMOPOSIn Network OnlyIn/Out Of Network Employer Contributions * 100% Employer Paid50/50 Employer/Employee Paid100% Employee Paid Orthodontia Benefits * YesNo Calendar Year Deductible * $ 25$ 50 Calendar Year Maximum * $ 1000$ 1500 Currently Insured * YesNo # Employees To Be Quoted * 12345678910111213141516171819202122232425262728293031323334353637383940414243444546474849