Please complete the form below to create a quote.
For Effective Dates through 12/1/2023
.
Agent/Agency Information
Name:
Email:
Phone Number:
Group Information
Employer Name:
State:
Please choose...
Alabama
Alaska
Arizona
Arkansas
California
Delaware
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Michigan
Minnesota
Mississippi
Nebraska
Nevada
New Mexico
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
West Virginia
Wisconsin
Wyoming
District of Columbia
Zip Code:
Industry Code:
Please choose...
Agriculture (0000-0999) (-12.5%)
Mining and Construction (1000-1999) (-12.5%)
Manufacturing (2000-3999) (-12.5%)
Transportation and Utilities (4000-4999) (-12.5%)
Trade (5000-5999) (+0%)
Finance (6000-6999) (+12.5%)
Services (7000-9099) (+0%)
Public Administration (9100-9999) (+12.5%)
Dental Plan Design
Plan:
Please choose...
Plan A (PPO)
Plan B (MAC)
Plan C (MAC)
Plan D (MAC)
Employee Enrollment:
<10 Employees (+10%)
10-50 Employees (+0%)
>50 Employees (+0%)
Deductible:
$150 Lifetime (+0%)
$100 Lifetime (+15%)
$50 Annual (+35%)
Annual Maximum:
$1,000 Annual Maximum (+0%)
$1,500 Annual Maximum (+5%)
$2,000 Annual Maximum (+10%)
$3,000 Annual Maximum (+15%)
Additional Options
Diagnostic & Preventive does not apply to Annual Maximum (+5%)
Move Endo/Perio/Oral Surgery to 80% Coinsurance (+10%)
Add $1,000 Child Orthodontics (+$8.66 [EC & EF])
Add Vision
Vision Plan Design
Plan:
Please choose...
BrightBenefits 1
BrightBenefits Expanded 1
BrightBenefits 2
BrightBenefits Expanded 2
Participation:
Please choose...
Voluntary
Non-Voluntary
Submit
