Page 47 - EJS Flipbook Employer

Group PPO Dental Proposal for
EJ Sprague

Premium Summary Network Access Plan 3 Usual, Customary, and Reasonable

Situs Zip (State) Lives
21921 (MD) 6

Monthly Monthly Rates
Employee +Spouse +Child(ren) Family Prem & Lives
Employee $46.87 $95.62 $110.44 $165.69 $281.22
Employer $0.00 $0.00 $0.00 $0.00 $0.00
Total $46.87 $95.62 $110.44 $165.69 $281.22
Weekly Weekly Rates
Employee +Spouse +Child(ren) Family Prem & Lives
Employee $10.82 $22.07 $25.49 $38.24 $64.92
Employer $0.00 $0.00 $0.00 $0.00 $0.00
Total $10.82 $22.07 $25.49 $38.24 $64.92
Lives 6 6

Important Notes:
» Quote Date: 3/29/2021. Rates are valid from 1/1/2021 through 6/30/2021.
» Rates assume Voluntary coverage (20% or less employer contribution).
» A minimum of 5 enrolled employees is required.
» Dependent Children are covered up to age 26.
» A 2 year rate guarantee is included provided the employee participation requirement is met and and enrollment does
not change by more than +/‐ 25%.
» Industry Category ‐ SIC: Machinery, Equipment and Supplies ‐ 508x
» OON reimbursement limited to Usual, Customary, and Reasonable Charges.
Dentist can bill the patient for the difference if their charge is higher than Usual, Customary, and Reasonable.
» Major Services: There is a waiting period of 6 months for current and future insureds

Any commercial insurance group policy underwritten and issued by The Guardian Life Insurance Company of America, a New York
Domiciled mutual company, is a participating policy. It is not expected, however, that a dividend will be paid on any such group policies. All
coverage will be provided as set forth in the policies.

DentalGuard Dental Insurance Plan General Limitations and Exclusions:
This policy provides dental insurance only. Coverage is limited to those charges that are necessary to prevent, diagnose or treat dental
disease, defect or injury. Deductibles apply. The plan does not pay for: oral hygiene services (except as covered under Preventive Services),
orthodontic (unless expressly provided for), cosmetic or experimental treatments, any to the extent benefits are payable by any other payor
or for which no charge is made, prosthetic devices unless certain conditions are met, and services ancillary to surgical treatment. The plan
limits benefits for diagnostic consultations and for preventive, restorative, endodontic, periodontic and prosthodontic services. The
services, exclusions and limitations listed above do not constitute a contract and are a summary only. The Guardian plan documents are the
final arbiter of coverage.
DG2000, et al.
The DentalGuard® policy is underwritten by The Guardian Life Insurance Company of America and offered through Allstate Benefits.
DentalGuard® is a registered servicemark of The Guardian Life Insurance Company of America (''Guardian''), used with permission.
Guardian is not responsible for the statements in this material. Allstate Benefits is authorized to offer certain DentalGuard® policies
underwritten by Guardian, but Allstate Benefits is not an affiliate or related entity of Guardian.
Home Office Use: 6.2021 / 5.1.2021 / 21921 / 508x / 0.12 / 0 / 6

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