Delta Dental

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About Delta Dental

Oral Health and Wellness

Delta Dental Request for Proposal (RFP) Assistant

The Member Company you selected is: DELTA DENTAL OF NEW JERSEY

Marketing and Sales Contact:

John Gumkowski

Phone:

860-633-9200

FAX:

860-633-3265

E-mail:

jgumkowski@deltadentalnj.com

Mailing Address:

148 Eastern Blvd., Ste. 310

Glastonbury, CT 06033

Web Site:

www.deltadentalnj.com

Required fields are indicated with an asterisk (*).

1. Tell us a little about who you are!

	*First Name:
	*Last Name:
	Company:
	Title:
	Street Address:
	Address 2:
	City:
	State:
	Zip Code:
	Country:
	Phone:	- -
	Fax:	- -
	*E-mail:

2. Please choose:

Are you a:

Employer Benefits Professional
Dental Health Benefit Consultant
Insurance Broker

If you are a Dental Health Benefit Consultant or an Insurance Broker, please answer the following questions:

	Company Representing:
	Client Company:
	Client Address:
	Address 2:
	City:
	State:
	Zip Code:
	Country:

3. Tell us a little about the company/client:

Where is the company's home office?

	City:
	State:

Is this where the benefit buying decision is made?

	Yes No
	If "No", where is the decision made?
	City:
	State:

What is the company's SIC Code?

SIC Code:

What is your estimate of the total employees and family members?

	Employees:
	Add'l Family Members:

Does the company currently offer a dental benefit to its employees?

Yes No

If you answered "No" above, please skip to section 5.

4. If you answered YES, then:

Please indicate the type of plan currently offered:
(check all that apply)

	Traditional indemnity
	Preferred Provider
	Dental HMO

Is this a voluntary program or does the company pay all or part of the benefit?

	Voluntary
	Employer pays all
	Employer/Employee contribution

When does the contract with the current carrier expire?

Date:

Who is the current carrier?

Name:

Why are you looking for a new dental benefits carrier?
(check all that apply)

	Dissatisfied with service
	More plan options needed
	Company policy to re-bid
	Better cost/value
	Larger network needed
	Other

How soon will you need a formal bid response?

Date:

5. If you answered NO, then:

What type of dental benefits plan are you interested in?

	Traditional indemnity
	Preferred Provider
	Dental HMO

How soon would you like the program in place?

Date:

How soon will you need a formal bid response?

Date:

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

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