RFP LIBERTY Dental Plan

LIBERTY Dental Plan

3200 El Camino Real, Suite 290
Irvine, CA 92602
(888) 273-2997
(949)223-0007
Fax (949)223-0011

Request for Proposal
Agent/Broker/Consultant Information:
Agent/Broker/Consultant Name:	(required)
Agent/Broker/Consultant Firm Name:	(required)
Phone:	(required)
Fax:
Email:	(required)
Address:	(required)
City:	(required)
Zip:	(required)
LIBERTY Broker/Agent ID:	(N/A if you do not have one)
Group Information:
Group Name:	(required)
Proposed Effective Date:	(required)
Group Zip Code:	(required)
Business Type:
Eligible Employees (required)
Employee Only:
Employee + Spouse:
Employee + Child(ren):
Family:
Employer Contribution (required)
Employee Only:	(percent or dollar amount)
Dependents:	(percent or dollar amount)
Voluntary Plan:	Yes No (required)
Current Dental Plan Information
Carrier Name:
Upload Current Benefit Plan:
Current Rates:
Plan Type	Select Type PPO DHMO Indemnity Other
Employee Only:	$
Employee + Spouse:	$
Employee +Child(ren):	$
Family:	$
Plan Type	Select Type PPO DHMO Indemnity Other
Employee Only:	$
Employee + Spouse:	$
Employee +Child(ren):	$
Family:	$
Additional Info: