/GroupDentalInsuranceQuote (Group quote & thank you)

Give Your Employees Something to Smile About, Partner with Momentum Plans for Your Group Dental Insurance

Looking for a quote on Group Dental Insurance? Your search ends here, with Momentum Plans! We are dedicated to providing Wisconsin businesses, of any size, with dental plans adressing their unique needs. From employer-sponsored to voluntary dental insurance, we will customize a plan perfect for your business and employees.

When you choose Momentum, you choose affordable, flexible dental insurance for your employees. Not only is dental insurance a great incentive as part of a benefits package, it will ensure your employees stay happy and healthy. When your employees visit the dentist regularly and get the oral care they need, your company will experience reduced sick days and improved productivity.

Flexible Group Dental Insurance Plans Meeting Your Exact Needs

Don’t want to pay for your employee’s dental insurance? No problem! Since Momentum’s group dental insurance plans are customized for each business, you choose how much you pay vs how much your employees pay. Most employees are merely happy to have the convenience of getting dental insurance through their employer, and will gladly pay for their premiums through payroll deductions – using pre-tax dollars to boot.

Paying for part or all of your employees’ premiums is beneficial to the employer too! Generally, businesses can deduct 100% of the premiums paid on qualifying group dental plans.

Complete the Group Dental Quote Form above to get started on the path to insured employees today or contact Momentum Insurance Plans if you need more information.

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Plan and Coverage Options

Step 1 of 5

SELECT YOUR PLAN (must choose an option)

Protect Plan:

Dental Health Associates Network

Gold Plan:

Dental Health Associates Network Commercial Network

Platinum Plan:

Dental Health Associates Network Commercial Network

Coverage Type

Single Couple Limited Family (1 adult + 1 child) Family Child/Children Only Number of children One Two Three Four

Select the number of Dependents One Two Three Four Five

Requested Effective Date

(must be the 1st of an upcoming month): //

Price Per Month:

(Plan and Coverage Type are Required for Pricing)

NEXT >

Member Information

Step 2 of 5

First Name*

MI

Last Name*

* Male Female

Home Address*

City*

State*

Zip Code*

Primary Phone*

- -

Email*

Marital Status Married Single

*Date of Birth

/ /

How have you heard about us?

Please Select an Option Referral by Momentum Insurance Agent Referral by Existing Momentum Customer Web Search I am a Repeat Customer Outdoor Billboards Radio Print Ad (Magazine/Newspaper) Television Social Media (Facebook/Twitter/LinkedIn) Other

Agents name:

Other:

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Dependent Information

Step 3 of 5

No dependent info is needed if you choose single in plan coverage.

1. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

2. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

3. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

4. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

5. Dependent Info

Male
Female

Date of Birth / /

Dependent Relationship (spouse, son, daughter) Spouse Son Daughter Other

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Coordination of Benefits & Prior Coverage

Step 4 of 5

Just a Couple More Questions:

Are you, your spouse, or other dependents(s) covered by any other dental plan that will remain in effect

Yes No

Which Family members will be covered? Self Spouse Dependent(s)

Select the number of Dependents

One Two Three Four Five

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Name of Person insured

Name of Person Policy is Issued to

Policy #

Name of Plan/Insurance Company

Address

Has applicant had previous dental coverage?

Yes No

Which Family members had previous insurance? Self Spouse Dependent(s)

Select the number of Dependents One Two Three Four Five

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /

Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

Name of Person Insured

Policy #

Name of Previous Plan/Insurance Company

Coverage Started On / /
Coverage Ended On / /

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Complete Your Purchase of a Momentum Insurance Plan

Step 5 of 5

MONTHLY COST:

Select Initial Payment Time:

3 Months

6 Months

12 Months

Total Due Today:

Cardholder Name:*

Email:*

Billing Address:*

City:*

State:*

Zip Code:*

Phone Number:*

Card Number:*

Expiration Date (MM/YY):*

Acceptance

I accept the Individual Plan coverage provided by Momentum Insurance Plans, Inc. I understand that by accepting insurance coverage, I am required to remit premiums according to the method of payment selected below on or before the 20th day of the month preceding the month of coverage for which payment is being made. Addition or deletion of dependents, and any other changes to coverage are allowed only based on a qualifying event as described in the Individual Plan policy. Coverage will be effective only upon acceptance and approval by Momentum Insurance Plans, Inc.

By signing this form, I certify that all information supplied is true to the best of my knowledge. I understand that all benefits for myself and my eligible dependents will be provided in accordance with the terms of the plan(s) in which I have enrolled and I agree to abide by the terms and conditions provided in the plan(s).

Please Sign The Electronic Signature Form Below

SAVE

CLEAR

Use your mouse or finger (if on touch screen device) to sign the document on the line above.

By my signature above, I authorize Momentum Insurance Plans, Inc. to initiate a debit entry to the credit card account (Discover, MasterCard, Visa) indicated above in the amount of 3 months premium for the initial payment. Each month thereafter, debits will be made on the 20th day of the month, prior to the coverage month, for each monthly payment. This authority is to remain in full force and effective until Momentum Insurance Plans, Inc. and said financial institution have received written notification from me of its termination in such time and manner as to afford Momentum Insurance Plans, Inc. and said financial institution reasonable opportunity to act upon it. This card will be used for reoccurring payments unless we hear from you. Please contact us at 608.729.6500 to make other arrangements for reoccurring payments.

Are you working with an agent?

Yes No

Agency Name

Agent Name

Agent #

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