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