Group Dental Inquiries

Group Dental Inquiries
1. Tell us a little about who you are!
*First Name:
*Last Name:
Birthdate:		If inquiring about individual dental insurance, please provide your birthdate.
*Company:
Title:
*Street Address:
*City:
*State:
*ZIP Code:
Country:
*Phone:
FAX:
*E-mail:

2. Please Choose
Are you a:	Employer Benefits Professional
	Dental Health Benefit Consultant
	Insurance Broker
If you are a Dental Health Benefit Consultant or an Insurance Broker, please answer the following questions:
Company Representing:
Client Company:
Address:
City:
State:
ZIP Code:
Country:

3. Tell us a little about the company/client:
Where is the company's home office?
City:
State:
Is this where the benefit buying decision is made?
	Yes No
If "No", where is the decision made?
City:
State:
What is the company's SIC Code?
What is your estimate of the total employees and family members?
Employees:
Add'l Family Members:
Does the company currently offer a dental benefit to its employees?
	Yes No If you answered "No" above, please skip to section 5.

4. If you answered YES, then:
Please indicate the type of plan currently offered: (check all that apply)
	Traditional Indemnity
	Preferred Provider
	Dental HMO
Is this a voluntary program or does the company pay all or part of the benefit?
	Voluntary
	Employer pays all
	Employer/Employee contribution
When does the contract with the current carrier expire?
Date:
Who is the current carrier?
Name:
Why are you looking for a new dental benefits carrier? (check all that apply)
	Dissatisfied with service
	More plan options needed
	Company policy to re-bid
	Better cost/value
	Larger network needed
	Other
How soon will you need a formal bid response?
Date:

5. If you answered NO, then:
What type of dental benefits plan are you interested in?
	Traditional Indemnity
	Preferred Provider
	Dental HMO
How soon will you like the program in place? Date:
How soon will you need a formal bid response? Date:

6. Is there anything else you would like to tell us about the company?

Marketing and Sales

Send Written Inquiries to:

Delta Dental of Michigan
Attn: Sales
P.O. Box 30416
Lansing, MI 48909-7916

Phone Numbers

877-335-8264 (Voice)

517-347-5420 (Fax)

Group Dental Inquiries

1. Tell us a little about who you are!

2. Please Choose

3. Tell us a little about the company/client:

4. If you answered YES, then:

5. If you answered NO, then:

6. Is there anything else you would like to tell us about the company?

Marketing and Sales