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Delta Dental of Kansas Request for Proposal
Section 1
First Name*
Last Name*
Company*
Title
Street Address*
Address 2
City*
State*
ZIP*
Phone*
Fax
Email*
Section 2
Please Choose One*


If you are a Broker, please answer the following questions.
Company Representing*
Client Company*
Client Address*
Address 2
City*
State*
ZIP*
Section 3
Where is the company's home office?*
Is this where the benefit buying decision is made?
If "No", where is the decision made?
The company's SIC Code
Estimated total employees*
Estimated additional family members*
Does the company currently offer dental benefits?
If you answered 'No' to the previous question, skip to section 5.
Section 4
Is this a voluntary program or does the company pay all/part of the benefit?
When does the contract with the current carrier expire?
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Who is the current carrier?
Why are you looking for a new dental benefits carrier? (check all that apply)


How soon will you need a formal bid response?
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RadDatePicker
Open the calendar popup.
Section 5: complete this section if company does not currently offer dental benefits.
How soon would you like the program in place?
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How soon will you need a formal bid response?
RadDatePicker
RadDatePicker
Open the calendar popup.
Section 6
Is there anything else you would like to tell us about the company?