American Denticare -- Group Voluntary Plans

The Employee Paid Group Dental Plan

Plan description: Our most popular employer plan. Employers are not required to contribute toward the premium. There is no percentage of employees that must take coverage. The only requirements are that the employer payroll deduct the premiums, accept the billing statement and pay once per month and a minimum of two employees must participate.

EMPLOYEE PAID GROUP DENTAL PLAN 103

Type of Service	Calendar Year Deductible	Percentage paid by Plan	Calendar Year Maximum Benefit		Waiting Period
PREVENTIVE - Exams, X-Rays, Prophylaxis (Cleanings), Flouride, Sealants, Space Maintainers	$0.00	100%	$1000.00		None
BASIC - Restorative Fillings, Denture and Bridge Repair, Tissue Conditioning, Non-Surgical Extractions, Anesthesia in connection with covered procedures	$50.00	80%			6 months
MAJOR - Crowns, Inlays, Onlays,Installation of Bridges and Crowns,Endodontics, Root Canals, Peridontics,Gum Disease Therapy, Oral Surgery	$50.00	50%			12 months
OPTIONAL
ORTHODONTIA - Braces (optional)	None	50%	$500 Annual Maximum	$1,000 Lifetime Maximum	24 months

Please complete the following concerning location and the number of potential participants:

Please enter your state
Please enter your Zip Code:
Number of employee only:
Number of employee & spouse:
Number of employee & children:
Number of full family:
Do you desire the Orthodontia Benefit?	Yes No
Is your group a government funded entity of any kind?	Yes No

EMPLOYEE PAID GROUP DENTAL PLAN 116

Type of Service	Calendar Year Deductible	Percentage paid by Plan	Calendar Year Maximum Benefit		Waiting Period
PREVENTIVE - Exams, X-Rays, Prophylaxis (Cleanings), Flouride, Sealants, Space Maintainers	$0.00	100%	$1500.00		None
BASIC - Restorative Fillings, Denture and Bridge Repair, Tissue Conditioning, Non-Surgical Extractions, Anesthesia in connection with covered procedures	$50.00	80%			6 months
MAJOR - Crowns, Inlays, Onlays,Installation of Bridges and Crowns,Endodontics, Root Canals, Peridontics,Gum Disease Therapy, Oral Surgery	$50.00	50%			12 months
OPTIONAL
ORTHODONTIA - Braces (optional)	None	50%	$500 Annual Maximum	$1,000 Lifetime Maximum	24 months

Please complete the following concerning location and the number of potential participants:

Please enter your state
Please enter your Zip Code:
Number of employee only:
Number of employee & spouse:
Number of employee & children:
Number of full family:
Do you desire the Orthodontia Benefit?	Yes No
Is your group a government funded entity of any kind?	Yes No

EMPLOYEE PAID GROUP DENTAL PLAN 117

Type of Service	Calendar Year Deductible	Percentage paid by Plan	Calendar Year Maximum Benefit		Waiting Period
PREVENTIVE - Exams, X-Rays, Prophylaxis (Cleanings), Flouride, Sealants, Space Maintainers	$50.00	80%	$1000.00		None
BASIC - Restorative Fillings, Denture and Bridge Repair, Tissue Conditioning, Non-Surgical Extractions, Anesthesia in connection with covered procedures		80%			6 months
MAJOR - Crowns, Inlays, Onlays,Installation of Bridges and Crowns,Endodontics, Root Canals, Peridontics,Gum Disease Therapy, Oral Surgery		50%			12 months
OPTIONAL
ORTHODONTIA - Braces (optional)	None	50%	$500 Annual Maximum	$1,000 Lifetime Maximum	24 months

Please complete the following concerning location and the number of potential participants:

Please enter your state
Please enter your Zip Code:
Number of employee only:
Number of employee & spouse:
Number of employee & children:
Number of full family:
Do you desire the Orthodontia Benefit?	Yes No
Is your group a government funded entity of any kind?	Yes No

EMPLOYEE PAID GROUP DENTAL PLAN 118

Type of Service	Calendar Year Deductible	Percentage paid by Plan	Calendar Year Maximum Benefit		Waiting Period
PREVENTIVE - Exams, X-Rays, Prophylaxis (Cleanings), Flouride, Sealants, Space Maintainers	$50.00	80%	$1500.00		None
BASIC - Restorative Fillings, Denture and Bridge Repair, Tissue Conditioning, Non-Surgical Extractions, Anesthesia in connection with covered procedures		80%			6 months
MAJOR - Crowns, Inlays, Onlays,Installation of Bridges and Crowns,Endodontics, Root Canals, Peridontics,Gum Disease Therapy, Oral Surgery		50%			12 months
OPTIONAL
ORTHODONTIA - Braces (optional)	None	50%	$500 Annual Maximum	$1,000 Lifetime Maximum	24 months

Please complete the following concerning location and the number of potential participants:

Please enter your state
Please enter your Zip Code:
Number of employee only:
Number of employee & spouse:
Number of employee & children:
Number of full family:
Do you desire the Orthodontia Benefit?	Yes No
Is your group a government funded entity of any kind?	Yes No

If you currently have a voluntary plan available to your employees but the rates have increased, we may be able to offer better rates and waive our waiting periods. We would need to do a custom proposal for you, please click on the Request Proposal button to the left.

SPECIAL NOTES: Benefits are paid based on a usual and customary fee schedule. The fee schedule has been calculated in a method that will pay the full percentage of approved charges at a high majority of dental offices. If you are concerned about this you may ORDER A COPY OF THE FEE SCHEDULE to determine that this coverage is right for you, follow the link to "request inormation".

DISCLAIMER: This is only intended to be a brief summary of certain benefits available within the dental program. IT IS NOT INTENDED TO BE A POLICY, A CERTIFICATE OF INSURANCE, OR A SUMMARY PLAN DESCRIPTION. There are many provisions, limitations, and exclusions that will affect coverage. We will be happy to provide a sample policy for your review, follow the link to "request information".

Telephone Contact: 877-537-6453

E-Mail Contact: marketing@aiba.com