G/P Administration, LLC

Request a Dental Quote - click here for print version

Please fill out as much of the questionnaire as possible.
If you would like a medical quote, please call the office at 877-669-4869:

Group/Company Name

Contact

Address

City

State

Zip

E-mail

Phone

Fax

Do you currently provide
employees a dental plan?

YES NO

If Yes, What Dental Company?

HMO
PPO
Indemnity
Self-Insured

Date plan began

# of Tiers in Current Plan
(1, 2, 3, 4)

Current Rates for Current Plan

Employee Only $
Employee + Child $
Employee + Spouse $
Employee + Family $

Effective Date for DR Proposal

Current Data

# of Employee Only
# of Employee + Child
# of Employee + Spouse
# of Employee + Family
# Total

Percent of Eligible Employees Enrolling

Percent of Eligible Dependents Enrolling

Percent of Employee Contribution Paid By Employer

Percent of Dependent Contribution Paid By Employer

100% of First $50, 50% of next $300, Maximum Annual Benefit =$200

100% of First $150, 80% of next $700, Maximum Annual Benefit =$500

100% of First $100, 80% of next $500, 50% of next $500, Maximum Annual Benefit =$750

100% of First $100, 80% of next $250, 50% of next $1400, Maximum Annual Benefit =$1000

100% of First $200, 80% of next $500, 50% of next $800, Maximum Annual Benefit =$1000

100% of First $300, 80% of next $750, 50% of next $600, Maximum Annual Benefit =$1200

100% of First $500, 50% of next $3000, Maximum Annual Benefit =$2000

100% of First $250, 80% of next $750, 50% of next $1300, Maximum Annual Benefit =$1500

100% of First $500, 80% of next $500, 50% of $500, Maximum Annual Benefit =$750

Create your own plan...

% of $ , % of $ , % of $ , Maximum Annual Benefit = $

G/P Administration, 566 Union St. Manchester, NH 03104 Tel: 877-669-4869