Copyright 2009 Harman Stone Corp.. All rights reserved. Harman Stone Corp. operates as a corporation nationwide.  Conditions of Use.  This Website is for illustrative, informational purposes only.  While Harman Stone Corp. believes the information to be accurate, final rates, benefits and group and/or individual acceptability will be determined at the appropriate time by the underwriting carrier.  No warranties are made regarding rates, underwriting requirements, transfer benefits, nor industry acceptability.  Harman Stone Corp. generates this Website for its clients and prospective clients in order to ease the decision making process.  Harman Stone Corp. insists that all of our clients and prospective clients consult not only this Website, but also primarily the actual carrier illustrations and brochures.  Harman Stone Corp. does not provide legal, tax, or accounting advice, nor should anything herein be construed as legal, tax, or accounting advice.  Prior results do not guarantee a similar outcome. Results depend upon a variety of factors unique to each client. Please direct all inquiries to Harman Stone, Corp., 2095 Exeter Road  Suite 106, Germantown, Tennessee 38138-3919, Offices: (901) 756-9800

Copyright 1994-2009 Harman Stone Corp.  |    Offices     (901) 756-9800
                 www.HarmanStone.com                |    Facsimile (901) 756-9888

Small Business Serving Small Business

      Group Dental
Request for Proposal

*First Name
*Last Name
Title
E Mail
Web Site
*Company
*Office Telephone
Office Facsimile
Street Address
City
State	TennesseeArkansasMississippiMissouriAlabamaGeorgiaPennsylvaniaWashington, D.C.Other
Zip Code
# of Employees
Current Group Dental Plan?	YesNoUnknown
Dental Plan Renewal Date
Dental Plan Carrier	AmeritasAssurant / John AldenBlue Cross / Blue ShieldDental SolutionsHumanaUnited HealthcareOther
Agent/Broker (Confidential)
Group Health?	Assurant / John AldenBlue Cross / Blue ShieldHumanaUnited HealthcareSelf-FundedOther
Group Short Term Disability
Group Long Term Disability
Supplemental Insurance	AFLACAllstate WorkplaceAmerican FidelityAmerican HeritageColonialCombinedConsecoTricareUNUM
Section 125 Cafeteria Plan	YesNoUnknownYes, Premium OnlyYes, Full PlanYes, POP and Unreimburse Med OnlyYes, POP and Dep. Care Exp. OnlyYes, POP and Both FSA's
Section 125 Plan Date
401(k) / Pension Plan
Curent Dental Plan Info.:
Group Dental Plan Name
Type of Plan	Indemnity (No Managed Care)Preferred Provider Organization (PPO)Point of Service Plan (PoS)Dental Maintenance Organization (DMO)Unknown
Network
Dental Office Visit Co-Pay	$25$30$35$40$45$50$75OtherUnknown
Specialist Co-Pay	$25$30$35$40$45$50$75OtherUnknown
Deductible	$50$100$150$200$250$300$500OtherUnknown
Deductible Carryover?	YesNoUnknown
Deductibles per Family	123OtherUnknown
Annual Maximum	$1,000$1,500$2,000$2,500$3,000$3,500$5,000OtherUnknown
Maximum Out-of-Pocket Indv.	$500$1,000$1,500$2,000$2,500$4,000$5,000OtherUnknown
Maxiumum Out-of-Pocket Fam.	$1,000$1,500$2,000$2,500$3,000$3,500$5,000OtherUnknown
# of Employees Participating
Employer EE Contribution	0%100%75%50%25%OtherUnknown
Employer Dep. Contribution	0%25%50%75%100%OtherUnknown
Employee EE Contribution	100%75%50%25%0%OtherUnknown
Employee Dep. Contribution	100%75%50%25%0%OtherUnknown
EE's with EE Only Coverage
EE's with EE and Child Coverage
EE's with EE and Spouse Coverage
EE's with Fam Coverage
Current Total Monthly Premium
Current Monthly EE Only Premium
Current Monthly EE and Child Premium
Current Monthly EE and Spouse Premium
Current Monthly Fam Premium
Current Rate Increase/Decrease	+5%+10%+15%+20%+25%+30%-5%-10%Other / Unknown
Last year's Rate Increase/Decrease	+5%+10%+15%+20%+25%+30%-5%-10%Other / Unknown
Additional Comments / Questions?