Cost Estimation Request Form (* fields are required) back to Forms page

SECTION I : General Information

Group Name*: Contact*:

Address*: City*:

State*: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming 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: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming Zip: City:   State: Select a State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Guam Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Puerto Rico Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virgin Islands Virginia Washington West Virginia Wisconsin Wyoming   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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