RFP LIBERTY Dental Plan

LIBERTY Dental Plan

1230 Avenue of the Americas
Rockefeller Center
7th floor
New York, NY 10020
(888) 273-2997
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)
State:	Select State: Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming (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: