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Group Dental Coverage

Group Dental Coverage reimburses you for certain dental expenses according to written agreement. Dental benefits usually are provided under a contract between your employer or union (the plan's "sponsor") and an insurance company, sometimes referred to as a third-party carrier. There are several types of Group Dental Insurance such as: Indemnity Plans, PPO's, Dental HMO's and Discount Referral Plans.


Indemnity Plans:

Are the traditional form of dental insurance. You are free to choose your own dentist without penalty. The plan pays all or part of the dentist's fee to the extent that it does not exceed the Usual, Customary and reasonable fee( UCR) for that service.


PPO's: 

Are similar to indemnity plans in most ways, but patients are offered financial incentives to select their dentist from a list of dentists who have entered into an agreement with the insurance company to accept a pre-set fee.


Dental HMO's:

Are not dental insurance at all. Under these plans you must choose a participating dentist to receive benefits.


Discount Referral Plans:

Are plans are commonly "included" in membership in some organization. The "insurance" pays nothing to the provider at all. Typically, in return for having a patient from the organization referred to his practice, the dentist provides "free" examinations and gives some percentage discount to the members.

 

 

Policyholder Name:
Contact Name:
City:
State:
ZIP Code:
Phone:
FAX:
E-mail Address:
Existing Carrier:
Current Plan:
Current Rate:
Effective Date: / /
Renewal Date: / /
Current Rates:
Single:
Husband/Wife:
Parent/Child:
Family:
Plan Design: HMO
POS
In Network Only
In/Out Of Network
Contributions: Employer Paid
Employee Paid
Employer and Employee Paid
Calendar Year Deductible: $25
$50
Calendar Year Maximum: $1000
$1500
Orthodontia Benefits: Yes
No

For groups over 5 employees, please fax your census to 201-703-0045!!

Employee #1

DOB: / /
Sex:Male
Female
Coverage:Single
Husband/Wife
Parent/Child
Family

Employee #2
(if applicable)

DOB: / /
Sex:Male
Female
Annual Salary:
Coverage:Single
Husband/Wife
Parent/Child
Family

Employee #3
(if applicable)

DOB: / /
Sex:Male
Female
Annual Salary:
Coverage:Single
Husband/Wife
Parent/Child
Family

Employee #4
(if applicable)

DOB: / /
Sex:Male
Female
Annual Salary:
Coverage:Single
Husband/Wife
Parent/Child
Family

Employee #5
(if applicable)

DOB: / /
Sex:Male
Female
Annual Salary:
Coverage:Single
Husband/Wife
Parent/Child
Family