GROUP APPLICATION

GENERAL INFORMATION:

Name of Group: Phone: Address: Fax: City/State/Zip # of Eligible Employees County: Group Tax ID#

CONTACTS: (Please include titles)

Administration: Title: Email: Enrollment: Title: Email: Billing: (name & location)

ELECTRONIC ENROLLMENT: Yes No AUTOMATIC DEDUCTION OF PREMIUMS: Yes No - If yes, please attached a voided check. ELECTRONIC BILLING: Yes No - Email:

ELIGIBILITY INFORMATION:

Dependents will be covered through the end of the birth month or calendar year.

-Primary dependents covered to age: AND

-Full-time students covered to age: OR IRS dependents covered to age:

PLAN DESIGN AND RATES: Plan # Effective Date: Renewal Date: Preventive %     Rates:   Basic % $ Contract Maximum (per member, per contract period) $ Employee Major %     $ EE + 1 Deductibles: (per contract period)   $ Family Orthodontic $ Lifetime Ortho Maximum (per member)                 Chamber Plan: Yes No If Yes, name of chamber: Note: All chamber information will be verified with designated chamber before group is installed.

CONTRIBUTION LEVEL: Employer pays: Employee pays:

BROKER INFORMATION: Name: *Firm: Address: Phone: City/State/Zip Fax: Email Address: Tax ID#

Is the firm incorporated? Yes No

*Commission will be paid to the firm unless otherwise agreed upon.