Please fill out the below form to have the quote information emailed to us.

		Proposed Effective Date:
REQUESTED BY:		Agent/Broker  TPA  Other
Name:
Company:
Address:
City:		State:		Zip:
Phone:		Fax:
Cell or Pager:		E-mail:
EMPLOYER INFORMATION
Company:			Type of Industry:
Street:
City:		State:		Zip:
Total Number of Employees:		# of Locations:
Employer's Contribution:	% of Employee Cost % of Dependent Cost
REQUESTED COVERAGE:
Dental  Vision  Dental with Vision		12/12 or  12/15
New Benefit Plan Description:
Orthodontia is included in plan, a separate benefit or not offered.
Orthodontia coverage is offered for child only to age , or to all participants?
Orthodontia Benefit is % to a Max of $ per year to a Lifetime Max of $ .
Employee Census:		EE Only	EE+1	EE+2	EE+Fam
		#	#	#	#
Will the Plan cover Retiree's? Yes No		Total of All Eligible Enrollees:
Please fax a copy of either the ADA or AAO cost estimates for the proposed DR/DA plan to (760)323-1896.
CURRENT PLAN INFORMATION:
Is there an existing Plan? Yes No		Copy of existing Plan Faxed: Yes No
Existing Plan Description:
Paid Claims:		For the Period of:
Paid Claims:		For the Period of:
		EE Only	EE+1	EE+2	EE+Fam
Current Premium rates:		$	$	$	$
Number of Enrolled Ee's:		#	#	#	#
Does the Plan cover Retiree's? Yes No		Current Plan Renewal Date:
PLAN ADMINISTRATION:
Claims will be paid by:
Mailing Address:
City:		State:		Zip:
E-mail Address:		Phone:
		EE Only	EE+1	EE+2	EE+Fam
Is there an Admin Fee?		$	$	$	$

Any information provided will not be submitted to any agency outside of Dentafits, Inc.