Insurance Benefits Planner

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Phone *	Email *

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What The Plan Pays

List All Benefits: By Category, By Code

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For multiple, separate by '+' (ie. 1256+8746+1254)

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This plan is a traditional indemnity insurance plan available to all dentists. Your dentist does not have to be part of a network. Please mention this to your dentist.

Paid Benefits For Visit

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Immediate Plan Benefits

Benefits After 6 Months

Benefits After 1 Year

* The following states have no 6 month waiting period:
CT, IL, KS, ND, OH, OR, SC, WV

Dental Wellness Benefits (exams, x-rays, etc.) are limited to:

Level 1 - Basic	$75 per 5 months - $150 max per year
Level 2 - Intermediate	$100 per 5 months - $200 max per year
Level 3 - Plus	$100 per 5 months - $200 max per year
Per Person Per Year

Max Benefits Per Year (Basic + Major):

Level 1 - Basic	$500
Level 2 - Intermediate	$1,000
Level 3 - Plus	$1,500

Would you like more information or to sign up?

visit www.dentalquick.com

or call us: 1-888-350-2416

or fax us: 1-888-770-8818

Your Name: ________________________

Your Phone #: ______________________

Your Email: ________________________

Rates as low as $16 / month

Amount shown is only an estimate. Please refer to your active insurance contract for complete coverage details.