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Get Dental Select Broker Quote Request Form

Yees: Fax #: # on Current Plan: Multi-location: Y N If yes, specify: El P/ SA/ Texas Only DFW/ AUS/ HOU/ Current Plan Information Current Rates Renewal Rates $ $ $ $ $ $ $ $ Dental Experience* Including: _____ Total Premiums Paid _____ Total Claims Paid *Applies to groups over 100 Requested Plan Specifications Effective Date: Match Current: Voluntary Y N If no, please specify request below: Preventive: Basic: Contributory ______________% Employees ______________% Dependents Ma.

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