Individual Dental Individual Dental Individual Dental General InformationCompany*Full Name* First Last Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone Number*Email* Type of BussinessType of BusinessNo. of Full Time EmployeesNo. of Part Time EmployeesGive a complete description of any type of hazardous/dangerous duties performed by your employeesCurrent Group Life Insurance InformationCarrier / Company Name (Not Agency)Policy Expiration Date: Date Format: MM slash DD slash YYYY Premium Amt ($):Years Insured:Please give a brief description of your current Group Life Plan.Benefits DesiredAmount of Life Insurance Per Employee$5,000$10,000$25,000$50,000$100,000$250,000$500,000$1,000,000OtherDental CoverageYesNoPPO OptionYesNoDisability Insurance$200$250$300$500$1000HMO OptionYesNoOptional Pregnancy CoverageYesNoSupplemental Accident CoverageYesNoEmployee InformationPlease list all participating employees you wish to coverName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyName First Last Date of Birth Date Format: MM slash DD slash YYYY Zip CodeGenderMaleFemaleDependent StatusEmp. OnlyEmp. + SpouseEmp. + ChildEmp. + FamilyIf you were not able to list all employees you wish to cover in the spaces above, please add them below or indicate that you will fax or e-mail an additional listingFinal Questions/CommentsComments / Remarks
