Superior Dental Care Secure Form
Use this form to request an underwritten quote for your group.
REQUEST UNDERWRITTEN QUOTE
Contact Information
Contact Name:   Email Address:     Phone Number:  
General Information
Date Rate Needed:  
Company:
City:
County:
State:
Broker Firm:
Broker Name:
# EEs:
Effective Date:  
Renewal Date:  
Current Coverage
Census Info Current Rates Renewal Rates
 
EE: EE: EE:
EE + Sp: EE + Sp: EE + Sp:
EE + Ch: EE + Ch: EE + Ch:
EE + Chn: EE + Chn: EE + Chn:
Family: Family: Family:
Waived: Composite: Composite:
Cobra: ASO Admin Fee: ASO Admin Fee:
Total Enrolled:
Total Members:
Plan Design
  In-Network Out-of-Network
Preventative:
Basic:
Major:
Contract Max:
Ortho:
Ortho Max:
Deductible:
Copay:
Current Carrier:
Yrs with Carrier:
Current ER Contribn:
Underwriting Instructions
Yes No
Employer Contribution: Out of State Employees:
Rate Guarantee: Commission Request:
Cap: Special List of
Covered Services:
Special Instructions/Notes:
Plan Designs to Quote
 
ASO Plan: Funding Rates: Admin Fee:
Fully-Insured: Supplemental Plan(s): Superior Vision:
Plan A Plan B Plan C Plan D
check one: check one: check one: check one:
Open Access Open Access Open Access Open Access
Network Only Network Only Network Only Network Only
Point of Service Point of Service Point of Service Point of Service
In Out In Out In Out In Out
Preventive:
Basic:
Major:
Contract Max:
Ortho:
Ortho Max:
Deductible:
Copay (Amount):
 
For Direct Quotes:
Option 1 Option 2 Option 3
Yes   No Yes   No Yes   No
Funding Rates Funding Rates Funding Rates
Network Network Network
Admin Fee Admin Fee Admin Fee
           
of first of first of first
of next of next of next
of next of next of next
Contract Max:  
 
 
Ortho: of first of first of first
Ortho Max: