Census for Group Dental
COMPANY
Name:
City:
Zip:
(Please be specific)
Phone:
PLAN DESIGN
Deductible
50 100
Maximum Benefit
1,000 1,200 1,500 2,000
Orthodontics
No Yes
EMPLOYEE CENSUS
Employee Name
Spouse
Children
No 1 2 3+
Comments or Questions: (Please include any pre-existing conditions and medications you are aware of.)
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