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* 1. Office/Employer Name:

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* 2. Name(s) of dentists at this office:

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* 3. Office Location

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* 4. Phone Number

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* 5. Current Health Insurance Carrier (if any)

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* 6. Current number of employees enrolled or that need coverage: _______

(if no existing coverage, how many employees need coverage and are willing to get a quote - this is the number that we need to reach 1,500 statewide )

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* 7. Employer Contribution % of Single premium (must be at least 50%)

(it is a requirement for all employer health plans in Nebraska that the employer contribute at least 50% of the single premiums.  If an employer is not willing to do this, they cannot enroll for coverage through the program. )

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* 8. Number of total eligible employees (must be at least 2)

The number of total eligible means the number of employees you have that will meet the minimum hourly weekly work requirement and be offered coverage. 

For example, you may require employees to work 25 hours per week to be eligible.  If you have ten employees, but only 6 are eligible satisfying the 25 hr/week requirement, enter “6” for this question.  Each employer will have the opportunity to determine what your hourly minimum is.  

This number should include anyone that meets this hourly requirement even if they will be waiving coverage due to coverage elsewhere (spouse’s plan, Medicare, parent’s plan etc…). If you have part-time employees that will not be offered coverage, do not include them in this number.

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* 9. Primary Contact Name

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* 10. Primary Contact Email

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