Dental Insurance - Employer Request

Employer & Group Dental Request

If you are interested in offering our benefit plans to your employees or group members, please complete this request form. One of our administrators will contact you with a viable solution. Depending on your group size, we have list bill options and we can create a plan that best fits your group needs.

GROUP REQUEST FORM - Long Term Consumer Care, Inc.

Company Name:
Contact Name:
Address:
City:
State:
Zip Code:
Phone Number:
Email Address:
Number in Group:
Type of Benefits:
How did you find us:
Please include the specific type of information you would like us to send you so we can respond in a timely manner.

For immediate assistance, Please call
Long Term Consumer Care, Inc.
Toll Free at 1-800-544-9505

We understand the importance of protecting your privacy. Any personal information you provide will be considered strictly confidential and will not be shared with any third party organizations.

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LTCC is a trademark of Long Term Consumer Care, Inc. All other products mentioned are registered trademarks of their respective companies. Questions or problems regarding this web site should be directed to info@consumerbenefits.net.