For Agents Use Only:
Employer:
Preparing Agent/Agency:
Agent/Agency Email:(required)
Phone Number:
Zipcode:
State:
Choose
a Plan: 		Indemnity
PPO

Participation: 75%
Voluntary
Annual Maximum: $1,000
$1,500
$2,000
$3,000
Group
Size: 		2-4 enrolled
5-9 enrolled
10-149 enrolled
Add Options:
$1500 Orthodontia
Endo/Perio to Class B
$50/$150 Calendar Year Deductible
Credit for Prior Time (CPT)
Voluntary Participation Only
100% Family-related
Add Vision Plan:
Plan A - 12/12/12 $0/$0
Plan B - 12/24/24 $0/$0
Plan C - 12/12/12 $10/$10
Plan D - 12/24/24 $10/$10
Plan E - 12/12/12 $10/$20
Plan F - 12/24/24 $10/$20
Plan G - Materials Only $10