Cost Estimation Request Form (* fields are required)
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SECTION I : General Information
Group Name*: Contact*:
Address*: City*:
State*: Zip*:
Telephone*: Fax:
Are employees located at the above address:  Yes No
If No, then state city/state/zip of employees at each site:

City: State: Zip:
City:   State:   Zip:
Current dental benefits offered: Yes No

SECTION 2 : Direct Reimbursement Plan Designs to be calculated
100% of $100; 80% of $200; 50% to max. of $1000 (standard) per person family
100% of $100; 80% to max. of $1000 per person family
100% of $100; 80% of $500; 50% to max. of $1500 per person family
% of $ ; % of $ ; max of $ per person family

SECTION 3 : Employee Breakdown
Proposed effective date of Direct Reimbursement program*: / /
Total no. of employees* (Do not leave blank fields, please enter the number '0' for none):

Total = (Single
Emp +spouse Emp + chil Family )
Will employee contributions be required: No Yes
If yes, please indicate how costs will be shared:
Employee Coverage: Employee pays % Employer pays %

Dependent Coverage: Employee pays % Employer pays %

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