Laserfiche WebLink
Pre•Dent Coverage* ❑ Yes ❑ No (!f yes, complete the modules below) <br /> 1`otal number of employees and dependents with dental coverage <br /> Package Plan: <br /> Benefit Period: ❑ Calendar Year or ❑ Contract Year If Contract Year: to <br /> Benefit PeriOd Maximum: $ ($50—$2000 in$50 increments or Unlimited)(not applicable to Orthodontic Benefits,if any) <br /> Individuai Deductible: $ per benefit period ($25—$150 in$5 increments) <br /> Family Deductible: times (2 or 3) individual or$ (aggregate) <br /> Deductible applicable to Preventive Services: ❑.Yes ❑ No (std) Prior Deductible Credit: o Yes ❑ No <br /> Carry Over Credit: ❑ Yes o No(only available if benefit period is calendar year) <br /> Preventive Dental Services: ❑ % of U&C(50%—100%in 5%increments) or ❑ Indemnity Schedule <br /> (entire program must be paid at either U&C or Indemnity Schedule, except Preventive <br /> Services may be paid at 100%with the rest of the program paid on an indemnity basis) <br /> Primary Dental Services: ❑ °%of U&C (50%—100%in 5%increments) or ❑ Indemnity Schedule <br /> Major Dental Services: ❑Yes ❑ No If yes; ❑ %of U&C (50%—100%in 5%increments) or ❑ Indemnity Schedule <br /> Orthodontic Benefits: ❑ Yes ❑ No lf yes; o %of U&C(50%or 60%) or ❑ Indemnity Schedule <br /> Orthodontic Lifetime Maximum: $ Age Limit for Orthodontic Benefits: <br /> OTHER SPECIAL PROVISIONS: <br /> Standard Pre—existing appJ.ies, P7.an yea� cycle 11/Ol <br /> No changes to current plan at tY�is trme. <br /> - . . - . <br /> �r �a-�-,� � p � 11� .5' � <br /> uthori d Purchaser/T' e/DatC <br /> Marketing Representative/Date <br /> Underwriter/Date <br /> An Independent Licensee of the Blue Cross and Blue Shield Association <br /> OB 3172 Rev.7/97 'Any variations other than those specified require Start-Up Committee approval. page 4 <br />