Beam Dental | Direct Benefits Inc.

Beam Dental

Please complete the form below to submit a request.

Agent/Agency Information

Name:

Email:

Phone Number:

Group Information

Employer Name:

State:

Zip Code:

Industry:

Dental Plan Design

Employee Enrollment:

Contribution:

Deductible:

Annual Maximum:

Endo/Perio/Oral Surgery:

Coinsurance:

Tier:

Ortho Maximum:

Additional Options

Add Adult Orthodontia (same as child lifetime max) (+flat amount)