Broker Proposal Request

We are glad you are here.

Dental Health Services designs value engineered plans to fit the unique needs of any sized group. We provide excellent value through our Quality Assured network of dentists and have the flexibility to let your group name their budget for the plan that fits their unique needs. Our dedicated member services team prides itself on providing first class, responsive, friendly service. We are more than just a dental plan. Our employee owners put members before profits. Find out what makes the Dental Health Services difference today!

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:

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From their own mouth.

"I have been in the insurance business since 1973 and this is one of the best Dental Plans I have had the privilege to offer my clients!"
- Peggy Staats - LUTC