| CURRENT
PLAN DESIGN |
| DENTAL |
LONG
TERM DISABILITY |
|
Current
Insurance Company:
__________________________ |
Current
Insurance Company:
__________________________ |
| Deductible:
Single: $________ Family: $________
|
Waiting
Period:
90 Days _________ 180 Days _________ |
|
Coinsurance |
Monthly Benefit: _________% to $____________ |
|
In-Network
______%_____%_____% |
Own
Occupation
Defiinition: |
2 yrs___ 5 yrs___
to age 65____
Other __________________________ |
|
|
Out-Of-Network
______%_____%_____% |
Integration
Primary _______ Full Family _______
70% All Sources _______ |
|
Annual Plan Maximum: $___________
|
CURRENT
RATE |
RENEWAL
RATE |
Orthodontia: YES_____ NO_____ |
________per $100 |
________per $100 |
Lifetime
Ortho. Maximum:
_______% to $_________ |
RENEWAL
DATE: ______/______/_____ |
|
CURRENT
RATE
|
RENEWAL RATE
|
DBL |
E
$___________
ES $___________
EC $___________
ESC $___________ |
E
$___________
ES $___________
EC $___________
ESC $___________ |
Current Insurance Company:
______________________________
|
| RENEWAL
DATE |
CURRENT
RATE |
RENEWAL
RATE |
|
_____/_____/_____
|
Male $_________
Female $_________ |
Male
$___________
Female $___________ |
| |
RENEWAL
DATE: |
______/______/_____ |
Comments:
_______________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
|
