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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 *
ZIP Code *
E-Mail *
Phone *
Fax

Effective Date *
/ /
Plan Design *
Employer Contributions *
Orthodontia Benefits *
YesNo
Calendar Year Deductible *
$ 25$ 50
Calendar Year Maximum *
$ 1000$ 1500
Currently Insured *
YesNo
# Employees To Be Quoted *

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