GROUP DENTAL PLAN PROPOSAL REQUEST

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For a group specific dental plan proposal for your employees, please complete the following information. We will contact you shortly if we need any additional information or we will have a proposal back to you within 2 business days. You can contact us at 303-744-3007 or 1-800-807-0706 with any questions. Thanks!

Proposal Request Details:

	* Required fields
Date:	04/23/2024
Proposed effective date (first of month only):	/01/ *
Is your membership current with this organization?	Yes No *
First Name:	*
Last Name:	*
Phone #:	*
Phone Ext:
Email Address:	*
Verify Email Address:	*
Company Name:	*
Number of Eligible Employees:	*
Company Address:	*
Company Address 2:
City:	*
State:	Colorado
Zip:	*
Do you have a current group dental plan in place?	Yes No *
If yes, who is the carrier?
If yes, what is the current plan renewal date?	/01/
Do you work with an insurance agent?	Yes No *
If yes, please provide your agent’s name?
If yes, please provides your agent's phone #:
What is your SIC code or industry (be specific)?	*
Approximately what % of your employees reside outside Colorado?	*
Are you willing to contribute to the monthly cost?	Yes No *
Comments:

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Please Note: These Dental Plans and pricing are provided through a partnership between your organization and Beta Health Association, Inc. You must be a member of this organization to have access to this product. Information contained on this site is intended to be general in nature. Specific plan description will be included in all proposals. All plans are not available in all areas. Plan availability is based on location and industry. If you have any questions please contact us at 303-744-3007 or 1-800-807-0706.