For Agents Use Only: Employer: Preparing Agent/Agency: Agent/Agency Email:(required) Phone Number: Zipcode: State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Choose a Plan: Peak PPO Summit Select Both Participation: 75% Voluntary Group Size: 2-4 enrolled 5-9 enrolled 10-100 enrolled Add Options: Endo/Perio to Basic $1500 $2000 Annual Max/Person $1200 Adult and Child Orthodontia $0 $25/$75 $50/$150 Calendar Year Deductible   Is the group a Government, Hospital, Law Office, Municipality or School? 20% industry load Yes