Delta Dental Request for Proposal (RFP) Assistant

The Member Company you selected is:  DELTA DENTAL OF WYOMING

Marketing and Sales Contact:
   Stacy Zastoupil
Phone:
   800-735-3379
FAX:
   307-632-7309
E-mail:
   stacyz@deltadentalwy.org
Mailing Address:
   P.O. Box 29
   Cheyenne, WY  82003-0029
Web Site:
   www.deltadentalwy.org

Required fields are indicated with an asterisk (*).

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