AEGIS PACIFIC
Insurance Service
TEST PAGE - Do not use for Quotations
The DentAssure Dental Plan - Indemnity Coverage
Request for Proposal (2-149 Employees)
Group Name:
Broker:
Group Zip Code:
Broker's E-mail:
Requested Effective Date:
Broker's Fax No.:
Industry:
SIC Code:
Eligible Employees:
Date Quote Required:
Deductible (Calendar Year) Maximum 3 per Family
$0 Deductible * $25 Deductible $50 Deductible $75 Deductible $100 Deductible
Annual Maximum Benefit (Calendar Year) Employee and Each Family Member
Waiting Period For Major Services
Orthodontia (For groups of 5 more - 50% Benefits)
Coinsurance (Preventive% - Basic% - Major Services%)
