Request for Proposal

Request for Proposal

Use the form below to submit an online request for proposal. Our Sales and Marketing staff will be in contact with you upon receipt of your completed form. If you have any questions, or would like further information, contact the Delta Dental of Kansas Sales and Marketing department at 316-264-8413 or email marketing@deltadentalks.com.

Section 1

First Name*

Last Name*

Company*

Title

Street Address*

Address 2

City*

State*

ZIP*

Phone*

Fax

Email*

Section 2

Please Choose One*

I am an employer benefits specialist
I am an insurance broker
Other

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?

YesNo

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?

YesNo

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?

VoluntaryEmployer Pays AllEmployer and Employee Contribution

When does the contract with the current carrier expire?

Open the calendar popup.

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?

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?

Open the calendar popup.

How soon will you need a formal bid response?

Open the calendar popup.

Section 6

Is there anything else you would like to tell us about the company?

Type the code from the image