Voluntary dental offers employees to purchase dental coverage at group discounts.  
There must be a minimum of 5 applicants.  Please complete the form below and rates will be generated and sent via email or fax.

 

Benefit Design and Employee Census Form for North Carolina

Information about your company.

Date Possible Effective Date
Company name Phone #
Contact name Fax #
Address
City
State, Zip
County		 Type of Business
Contact Email Website

Information that will determine if the group qualifies for either Employer Sponsored or Voluntary programs.

Total number of full time employees: Total number to enroll:
Employer will contribute % of employee Employer will contribute % of dependents
Current Carrier Renewal Month
Current Rates:

E

E/C

E/S

E/F
   

Please choose desired benefit structure.

Services

Options
First Variable is most common

Choice
PREVENTIVE SERVICES:
Exam, x-rays, teeth cleanings

100% or 80%

BASIC SERVICES:
Fillings, oral surgery, root canals

80% or 90%

MAJOR SERVICES
Crowns, bridges, dentures

50% or 60%

ORTHODONTIC SERVICES
Straightening of teeth

50% or No Coverage

DEDUCTIBLE AMOUNT

$50, $25, or $ 100

DEDUCTIBLE WAIVED FOR PREVENTATIVE SERVICES?

Yes or No

GENERAL DENTISTRY ANNUAL MAXIMUM BENEFIT:

$1000 OR $1500

ORTHODONTIC LIFETIME MAXIMUM BENEFIT:

$1000 OR $1500

Information about your employees.

Employee name or initials

Age or DOB

Sex

Spouse
DOB

# of dependent children
1.

2.

3.

4.

5.

6.

7.

8.

9.

10.

11.

12.

13.

14.

15.

16.

17.

18.

19.

20.

If you have additional employees, fax them to (704-588-7971) using this same format.

Check here if you wish to have an agent contact you prior to quotes being generated.

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