Group Dental Quote Form

If you currently have a Group Dental plan in place we will need a copy of your most recent billing from your current insurance provider and a copy of your current benefit highlight sheet. You can scan and email a copy of your most recent billing and benefit highlight sheet to Kate Passalacqua at katep@weisinsurance.com or simply fax a copy to (217) 342-9876.

Personal Information

First Name *

Last Name *

Company Information

Company Name *

Street *

City *

State *

ZIP / Postal Code *

Primary Phone Number *

E-Mail Address *

Do you currently have insurance?

Current Insurance Provider

Current Policy End Date

Nature of Business

Are there any Major Medical Conditions? *

Describe any major medical conditions that exist.

Submission Validation

Required

Important Notice
Any submissions or payments made via this website do not constitute a binding agreement to your policy or coverages. Changes and payments to policies are not effective or binding until you, or any party involved, receive official notice from either your insurance agent, or your insurance company. If you have any questions, please feel free to contact us.

Per the terms of our online privacy policy we will not resell your information to any third-party.

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