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Direct Reimbursement
Dental Estimate Form

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Company Name:
Nature of Business:
Contact Name:
Address1:
Address2:
City: State: Zip:
Telephone:
Fax:
1. Is there a current dental benefit program in place?
Yes No
Date Implemented:
2. What is the anniversary date of your present dental benefit plan?
3. If no dental, what is the proposed date for the DR Plan?
4. Enter in total number of employees:
Males    Females
 

NUMBER ENROLLED IN
CURRENT DENTAL PLAN
(OR NUMBER IN MEDICAL PLAN)

CURRENT DENTAL
PREMIUM RATE

Employee Only Employee Only
Employee + Spouse Employee + Spouse
Employee + Child Employee + Child
Employee + 2 or more Dep. Employee + 2 or more Dep.
5. Are employees contributions required? Yes No
Employee Contributions%:
Dependent Contributions%:
Please list the State and number of employees in that State (example: OH 384)
6. What is most important to the employer in getting a DR proposal?
7. What are you most dissatisfied with in your current plan?

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?

Average Benefit
Plan 1 75% to $100, $50 deductible, 50% of balance 50%
Plan 2 100% or $100, $50 deductible, 50% of balance 55%
Plan 3 100% or $100, 50% of balance 60%
Plan 4 100% or $100, 70% of $100, 50% of balance 65%
Plan 5 100% of $150, 70% of $100, 50% of balance 70%

Annual Maximum:

$500 $750 $1000 $1250
Ortho: Max. $ Benefit Yes No

Yes (under 19 yrs only)
Vision: Yes No

If you do not find your plan above, design your own or contact us and we will design a plan for you.

Per Person Basis: Per Family
Basis
(check one only)
Annual Cost of Dental Services Covered Percentage Net Benefit $
First $ X % =
Next $ X % =
Next $ X % =
Next $ X % =

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


Administrative Office
Direct Reimbursement, Adm., Services, Ltd.
P.O. Box 292455
Kettering, OH 45429
Tel: 937/428-1046
Fax: 937/428-4831
email: admin@DirectReimbursement.com

Please Return Completed Form To: Ann Crouse
Direct Reimbursement Administrative Services
P.O. Box 292455
Kettering, OH 45429
Tel: 937/428-1046
Fax: 937/428-4831

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