Dental Insurance

Does your company offer or provide dental insurance coverage for your employees?      [ ] Yes    [ ] No

What length of service is required before employees are eligible for dental insurance?
          [ ] Hire Date    [ ] End Probation    [ ] One Month    [ ] Six months    [ ] Other _________________________

Are all employees eligible for coverage?      [ ] Yes    [ ] No

If no, which employees are not eligible?       [ ] Part Time    [ ] Other Please explain ________________________

Is coverage paid for by the Company?         [ ] Yes    [ ] No      If yes, what percentage is company paid?_______ %

Is dependent coverage paid for by the Company?    [ ] Yes    [ ] No    If yes, what percentage is company paid? _____%

What is the monthly cost to the employee for:      Employee coverage?    $_______      Dependent coverage?   $_______ 

What type of insurance do you offer?      [ ] Traditional      [ ] DMO      [ ] Other_______________________________ 

What is the annual deductible?      $ ___________

What is the annual maximum benefit?      [ ] $1,000      [ ] $1,500      [ ] $1,750      [ ] No Annual Limit      [ ] Other 

How many employees are currently insured on your plan? Is your company self-insured?    [ ] Yes    [ ] No

Are employees responsible to pay the company portion of the premium during leaves or other extended absences?               [ ] Yes     [ ] No       If yes, please explain below 

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