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NUMBER ENROLLED IN CURRENT DENTAL PLAN (OR NUMBER IN MEDICAL PLAN)
CURRENT DENTAL PREMIUM RATE
PLAN DESIGN OPTIONS
These are 5 examples of plans or we can match your current plan or design a new plan for you.
How much would you like to allocate to your dental plan per employee $ month?
Annual Maximum:
If you do not find your plan above, design your own or contact us and we will design a plan for you.
Annual Maximum Benefit: $
EXAMPLE PLAN DESIGN PER PERSON
First $100 x 100% = $100 Next $250 x 70% = $175 Next $250 x 60%=$150 Next $1000 x 50%=$500 Annual Maximum Benefit=$925
Please Return Completed Form To:
DR Administrative Services, Inc. 20 Broadhollow Road, Suite 3007 Melville, NY 11747
631-629-4110 1-888-791-DRDP (3737) (toll free number) 631 629-4111 (fax) 1-888-791-1313 (toll free fax) robr@dradmin.com
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