Dental Insurance RFQ

Thanks for your interest in the RepCare Program. Reading the material below will expedite the over-all process of providing quotations and moving towards the underwriting and enrollment process. Please answer ALL questions accurately and completely for the quickest and most accurate response.

EMPLOYEES: Current group insurance rules require that you list all full-time, payroll employees on your census form, even if they have medical coverage elsewhere. Please identify any employee who is covered elsewhere (i.e., through a spouse at another employer). Every full-time, payroll employee is required to complete an enrollment form, including health history questions, even though that employee is "waiving" coverage due to medical coverage elsewhere.

EFFECTIVE DATE: The process of getting quotes and completing enrollment and application forms, as well as the underwriting process by the carrier, have stretched out, and it is currently taking between 4 and 6 weeks, after all enrollment and application forms are received, for coverage to become effective. Please do not cancel your current coverage until a written acceptance by the new carrier has been received. Start this RFQ and enrollment process at least 2 months before you expect to change carriers.

REQUEST FOR GROUP DENTAL INSURANCE PROPOSAL/QUOTE

Association Affiliation:

Name and title of contact person completing this form:

Employer Name:

Address:

City:

State:

Zip:

Tel:

Fax:

email:

Please indicate all the RepCare programs for which you would like quotes:

	Group Medical
	Group Life
	Personal Accident
	Long Term Disability

CENSUS FORM:
Please list all full-time, payroll employees of your firm, even if covered elsewhere.

Employee 1
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 2
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 3
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 4
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 5
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 6
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 7
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 8
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 9
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 10
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 11
Name:
Age:
Residence ZIP:
Dependent Status:

Employee 12
Name:
Age:
Residence ZIP:
Dependent Status: