Number of Eligible Employees:

Will Coverage Include Retirees: Yes No
 

Employee Turnover Rate Per Year:

Select One 0%-10% 11%-17% 18%-25% 26%-33% 34%-40% Other Other:

Prior Dental Coverage:

          Select One None 1 Year 2 Years 3 Years Over 3 yrs

Current Dental Plan:

Traditional  Managed Care

Contribution:

          Select One Employer Paid Employee Paid Co-Pays

Comments:

Please contact me as soon as possible regarding this matter.