Group Proposal Request

Group Name:

Group Phone: Group Email:

Group Headquarters City:

Group Headquarters State:

Group Main Zip Code:

Does the group have prior coverage?
Yes No

Requested Effective Date: SIC Code or Industry Description: 3 or 4 tier Rate Request: Due Date:

Groups current premiums: Groups renewal premiums:

Groups current carrier:

How many employees do you project will participate?
Will the company pay for some or all of the employee's premium?
Yes No

How many total full-time employees are there?

Will the company pay for some or all of the dependent's premium?
Yes No

Other comments/notes:

Do you work with a broker?
Yes No

If so, can we contact them?
Yes No

Broker Name:

Broker Phone: Broker Email:

Dental Health Services