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Group Dental Insurance

Dental coverage is generally provided for preventive services, (cleanings, x-rays, and exams), minor restorative services (fillings), and major restorative services (crowns, bridges, root canals). Sometimes, but not often, orthodontia is covered.

We will automatically show you multiple plan options when we quote dental insurance.

The information required for quoting dental insurance is similar to health insurance. Therefore, if you have already completed our census information for heath, you do not need to complete this form again.

*Please Provide as much information as possible to assure the most accurate quotes. Leave blank if you are not sure of an answer.

*See our Privacy policy for confidentiality.

General Information

This section only needs to be completed once for multiple lines of coverage

Name of Business:

Name of Owners/Officers:

Contact Name:

Contact Phone & Fax:

Phone: Fax:

Contact E-mail Address:

Address:

City:

State: Zip:

Business Info:

C-Corporation
S-Corporation
LLC

Sole-Proprietor

Partnership

LLP/Other

Years in Business:

Fed. Tax ID or Social Security Number:

Business Description:

Current/Previous Insurance Information

Current insurance company:

Describe Your Current Dental Plan:

Policy Period:

Effective Date: Expiration Date:

Census Data Information

*Important Note*

If you have more than 10 employees, please open this Health Census Form (Adobe pdf) and

save it to your computer to type directly on it, or print it out to complete it by hand.

If you have 10 or less, complete your information below:

Employee Name	Sex	Dependent Status	DOB/AGE	Spouse DOB/Age	#of Children	Employee's
Employee Name	Sex	Dependent Status	DOB/AGE	Spouse DOB/Age	#of Children	State	Zipcode
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F
	M F

Additional Comments & Information

Please tell us anything else you think might be helpful to know in order to provide accurate insurance quotes:

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