Rapid Cost Estimate Form

Please note that filling out the entire form is not required, however the more information that is provided will allow us to provide a more accurate cost estimate. Thank you for filling out the Dental Direct cost estimate form.

Company Name:
Company Type:
Address:
City:
State:
Zipcode:
Contact Person:
Title:
Telephone:
Fax Number:
Email:

Company Information
Total number of employees eligible to participate in the dental plan:
Approximate annual employee turnover rate:
Do you have a Cafeteria Benefits Plan with medical and/or dependent flexible spending accounts?
Nature of company's business and/or SIC Code:
Address of additional employer sites (excluding the address listed above)
Location 2 Address:
Number of Employees:

Current Dental Plan Information
Do you currently offer a dental plan?
Insurer Name:
Year Policy Began:



Renewal Date:
Broker Name (if applicable):
Telephone:
Employee Only - Current Rates:
Employee Only - Number of Employees Enrolled:
Employee/Spouse - Current Rates:
Employee/Spouse - Number of Employees Enrolled:
Employee/Child - Current Rates:
Employee/Child - Number of Employees Enrolled:
Employee/Children - Current Rates:
Employee/Children - Number of Employees Enrolled:
Employee/Family - Current Rates:
Employee/Family - Number of Employees Enrolled:
Percentage of Cost Company Pays for Employees:
Percentage of Cost Company Pays for Dependents:
The Deductible per Individual:
The Annual Maximum per Individual:
The following percentages are paid for various types of procedures:
Percentage for Preventive Care:
Percentage for Basic Care:
Percentage for Major Care:
Percentage for Orthodontic Care:
Historical Paid Claims (please include any available information):
2010:
2009:
2008:
Any Additional Comments or Concerns:
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