Request for Proposal

Use our online form to submit a Request for Proposal

Online Form

Use the form below to submit an online request for proposal. Our staff will be in contact with you upon receipt of your completed form. If you have any questions, or would like further information, contact Delta Dental of Wyoming at 307-632-3313 or 1-800-735-3379 or email customerservice@deltadentalwy.org.

Employer Sponsored Plan Details

Plan	Coverage	Deductible	Employee Participation Requirements
10000 (No Ortho)	100/80/50	$50 per person/$100 Family	100% must be enrolled Minimum of 5 employees
11000 (With Ortho)	100/80/50/50	$50 per person/$100 Family	100% must be enrolled Minimum of 20 employees
50000 (No Ortho)	80/80/50	$50 per person/$100 Family	100% must be enrolled Minimum of 5 employees
51000 (With Ortho)	80/80/50/50	$50 per person/$100 Family	100% must be enrolled Minimum of 20 employees
30000 (No Ortho)	100/50/50	$50 per person/$100 Family	100% must be enrolled Minimum of 3 employees
31000 (With Ortho)	100/50/50/50	$50 per person/$100 Family	100% must be enrolled Minimum of 20 employees
80800 (No Ortho)	100/50	$50 per person/$100 Family	100% must be enrolled Minimum of 2 employees

Voluntary Plan Details

Plan	Coverage	Deductible	Employee Participation Requirements
Voluntary Plan (With Ortho)	100/75/50/50	$50 per person/$100 Family	50% must be enrolled Minimum of 20 employees (unless currently have Ortho coverage)
Voluntary Plan (No Ortho)	100/75/50	$50 per person/$100 Family	50% must be enrolled Minimum of 5 employees

Individual Plan Details

Please see our Individual Plan details located in the Subscriber Section.

Plan Design Requested

Voluntary Plan

Voluntary Plan (With Ortho)Voluntary Plan (No Ortho)

Section 1 - Broker/Agent Information

First Name*

Last Name*

Company*

Title *

Street Address*

City*

State*

ZIP*

Phone*

Fax

Email*

Section 2 - Group Information

Group Name*

Address*

City*

State*

ZIP*

Phone Number*

Section 3 - Census Information

Total Number of Employees*

Number of Single Employees*

Number of Employees Plus One*

Number of Families*

If the Group has Prior Coverage, please provide an outline or summary of coverage and rates if available

Type the code from the image

Delta Dental of Kansas