DentaQuest Benefit Solutions

Need a quote or proposal for one or more of our plans?

We would be happy to provide you with a customized proposal or price quote to present to your client. If you would like to receive a quote for any of our products, please submit the form below, or e-mail sales@dentaquest.com. Please provide us with a census, claims history, and any other relevant information about the group. We promise to respond within one business day of your submission.

Broker Information:

Broker Name:	Agency Name:
Address:	City:
State:	Zip:
Telephone Number: () -Second partThird part	Fax Number: () -Second partThird part
E-mail:	Due Date of Proposal:

Group Information:

Group Name:
Group Address (Headquarters):	City:
State:	Zip Code:
Telephone Number: () -Second partThird part	BusinessType with SIC or detailed description:
Number of Employees:	Effective Date:

Which products would you like to receive a proposal for? (Please check all boxes that apply.)

Dental Plans:

Indemnity Dental Benefits:	Voluntary PPO Dental Plans:
Employer Sponsored PPO Dental Plan:	Self-Funded Dental Plans:

Vision Plans:

Standard Plan:

Premier Plan:

Diamond Plan:

How many employees are eligible for benefits?:

Does the group currently offer dental benefits?:

What is the name of the current carrier?:

Will the employer contribute to the employee's premium?:

If yes, what percentage will the employer contribute?:

Does the group have eligible employees who live outside of Maryland, Virginia, and Washington D.C.:

Please send a census and claims history to: sales@dentaquest.com