Broker Proposal Request

Broker Name: Brokerage firm:

Broker address:

City:

State: Zip Code:

Broker phone: Broker email:

Group Info

Name of group:

Group Headquarters City:

Group Headquarters State:

Group Main Zip Code:

Does the group have prior coverage?
Yes No

Requested Effective Date: Requested Commission: SIC Code or Industry Description: 3 or 4 tier Rate Request: Due Date:

Groups current premiums: Groups renewal premiums:

Groups current carrier:

How many employees do you project will participate?
Will the company pay for some or all of the employee's premium?
Yes No

How many total full-time employees are there?

Will the company pay for some or all of the dependent's premium?
Yes No

Other comments/notes:

In this section:

From their own mouth.

"I have worked with Dental Health Services for the past 5 years. Your representatives have been professional, friendly, helpful and responsive. I have written several policies."
- Linda Mattos - Agent

Broker Proposal Request

In this section:

From their own mouth.

Dental Health Services

Ray Aguirre