Cost Estimate Form

Direct Reimbursement Administrative Services, LTD.

Direct Reimbursement
Cost Estimate Form

Company Name:
Nature of Business:
Contact Name:
Address1:
Address2:
City: State: Zip:
Telephone:
Fax:

Is there a current dental benefit program in place?
Yes No
Date Implemented:

What is the anniversary date of your present dental benefit plan?

If no dental, what is the proposed date for the DR Plan?

Enter in total number of employees:
Males Females

NUMBER ENROLLED IN CURRENT DENTAL PLAN (OR NUMBER IN MEDICAL PLAN)		CURRENT DENTAL PREMIUM RATE
Employee Only		Employee Only
Employee + Spouse		Employee + Spouse
Employee + Child		Employee + Child
Employee + 2 or more Dep.		Employee + 2 or more Dep.

Are employees contributions required? Yes No
Employee Contributions%:
Dependent Contributions%:
Please list the State and number of employees in that State (example: OH 384)

What is most important to the employer in getting a DR proposal?

What are you most dissatisfied with in your current plan?

PLAN DESIGN OPTIONS

How much would you like to allocate to your dental plan per employee $ month?

		Average Benefit
Plan 1	75% to $100, $50 deductible, 50% of balance	50%
Plan 2	100% or $100, $50 deductible, 50% of balance	55%
Plan 3	100% or $100, 50% of balance	60%
Plan 4	100% or $100, 70% of $100, 50% of balance	65%
Plan 5	100% of $150, 70% of $100, 50% of balance	70%

Annual Maximum:

$500

$750

$1000

$1250

Ortho: Max. $ Benefit	Yes	No	Yes (under 19 yrs only)
Cosmetics:	Yes	No
Vision:	Yes	No

If you do not find your plan above, design your own below:

Per Person Basis:

Per Family
Basis

(check one only)

Annual Cost of Dental Services		Covered Percentage		Net Benefit $
First $	X		% =
Next $	X		% =
Next $	X		% =
Next $	X		% =

Annual Maximum Benefit: $

EXAMPLE PLAN DESIGN PER PERSON

First $100 x 100% = $100
Next $250 x 70% = $175
Next $250 x 60%=$150
Next $1000 x 50%=$500
Annual Maximum Benefit=$925

Please Return Completed Form To:

Ann Crouse
Direct Reimbursement Admininstrative Services
P.O. Box 292455
Kettering, OH 45429
Tel: 937/428-1046
Fax: 937/428-4831

Administrative Office
Direct Reimbursement, Adm., Services, Ltd.
P.O. Box 292455
Kettering, OH 45429
Tel: 937/428-1046
Fax: 937/428-4831
email: admin@DirectReimbursement.com