Superior Dental Care Secure Form
Use this form to sign your group up for SDC dental coverage.
GROUP APPLICATION
General Information
Name of Group:
 
Total Employees:
 
Address:
 
# of Eligible Employees:
City/State/Zip:
     
Group Tax ID#:
 
County:
 
Phone:
 
SIC Code:
Fax:
 
Contacts  (Please include titles)
Administration:
Title:
Email:
Enrollment:
Title:
Email:
Superior Direct Connect:
Title:
Email:
Billing:
Title:
Email:
Automatic Deduction of Fees/ Premiums, please complete and mail the Authorization for Direct Payment
Eligibility Information
Dependents are covered to the maximum age of:  (SDC permits up to age 26 through the end of the birth month).
Plan Design
Contribution Levels:  Employer Pays:     EE Pays: 
Plan Detail:
Effective Date:
Renewal Date:
SDC group plan type:
ASO
The Direct Plan
Core and Enhanced Option
SDC-Kids plan:
Low Plan
High Plan
Network Option:
Open Access (In & Out of Network)
Point of Service
Network Only
Funding Option:
Fully-Funded
Self-Funded
Superior Vision:
Plan #
Tied to Dental
Employer Paid
Voluntary
Plan Design: Based on the SDC rate sheet and plan options available, please complete the information below. If one plan has been selected, please list the plan information in the first column below. If 2 or 3 plans are selected, please use the columns below starting with the first.
Plan:  Plan:  Plan: 
In Network Out of Network In Network Out of Network In Network Out of Network
Preventive % % % % % %
Basic % % % % % %
Major % % % % % %
Contract Maximum $ $ $
Deductible $ $ $
Copay $ $ $
Ortho % % % % % %
Ortho Max $ $ $
 
Vision Rates Dental Rates
Employee $ Employee $ Employee $ Employee $
EE+Spouse $ EE+Spouse $ EE+Spouse $ EE+Spouse $
EE+Child(ren) $ EE+Child(ren) $ EE+Child(ren) $ EE+Child(ren) $
Family $ Family $ Family $ Family $
Max Advantage(Preferred Plan Only)
Max Advantage Contract Maximum for Year 2 $
Max Advantage Contract Maximum for Year 3 $
Admin Fee
(if Self-Funded):
ASO Admin Fee
$
or
Direct Admin Fee
$
Reimbursement Schedule:
Level 1
Level 2
Level 3
Level 4
Ortho Max $
Contract Max $
With SDC's Network?
Yes
No
Approved Association/Chamber Plan  (if applicable)
Name of Approved Association/Chamber Plan: 
SDC offers plans to select chambers and associations. For a complete listing, please contact SDC. Note: All association/chamber information will be verified with designated chamber before group is installed.
Broker Information
Address:
   NPN#:
*Commission will be paid to the firm.
If this is your first sale with SDC, please complete and return the Producer Appointment Information Form. Please ask your sales representative for details.
Authorization
By entering my initials in the box below, I certify that I am an authorized representative of the company identified on this form and that any information submitted is accurate and current.
Initials: