Delta Dental - Brokers - Request for Proposal

One of our goals at Delta Dental of Massachusetts is to work with you to provide the best overall benefits with "real" cost containment and competitive pricing for your clients. Please complete the below Request for Proposal form and attach your clients' Census data (if available) and click submit to obtain a proposal.

Broker Information

Broker/Consultant Name:
Brokerage Name:
Address:
City:
State:
Zip:
Phone:
Fax:
E-mail address:

___________________________________________________________________________

Company Information

Clients' Company Name:
DBA (if applicable):
Address:
City:
State:
Zip:
Phone:
Fax:
HR Director:
E-mail address:
Type of Business or Industry:
SIC Code (if known):
Other locations or subsidiaries:

No. of Eligible Employees:
Requested Effective Date: mm/dd/yyyy
Company Currently has Coverage	Yes No