Pelican Dental Concepts

Free Stuffed Perci Pelican

* Marked fields are required

Contact Referral Form

* Employer name:

* Address:

* City:

* State:

* Zip:

How did you hear about Pelican Dental?:

* If you chose "Dentist" or "Other":

* Employer contact:

Title:

* Telephone:

() -

Fax:

() -

E-mail:

Number of employees (estimate)

Does the employer have a dental plan in place?

Yes

No

Not Sure

If yes, what is the name of the dental plan?

Is the plan:

Self-funded

Managed-care (PPO,PLHSP, HMO)

Fully insured (indemnity)

Other

Not sure

Please send Perci Pelican to:

* Company:

* Address:

* City:

* State:

* Zip:

E-mail:

* Telephone:

() -

Fax:

() -

May dental-benefits suppliers use your name when contacting this employer?

Yes

No

If requested, would you accompany a supplier's agent to meet with this employer to discuss the benefits of a self-funded dental-benefits plan?

Yes

No

Thank you for completing this referral form and for working towards educating employers on the benefits of self-funded dental plans.

This offer is available for a limited time only and while supplies last.