Delta Dental Indiana

Plan rates below are for clients with effective dates between 10/1/12–9/30/13
Plan A Plan B Plan C Plan D Plan E
Delta Dental PPO Delta Dental PPO Delta Dental PPO Delta Dental PPO Delta Dental PPO
(Point-of-Service) (Point-of-Service) (Point-of-Service) (Point-of-Service) (Standard)
Standard High Risk Standard High Risk Standard High Risk Standard High Risk Standard High Risk
Indiana Single $27.10 $30.09 $26.13 $29.02 $17.24 $19.16 $19.14 $21.25 $22.33 $24.81
2 Party $48.79 $54.20 $47.31 $52.56 $31.09 $34.54 $34.41 $38.22 $40.40 $44.88
Family $86.33 $95.88 $83.62 $92.89 $62.36 $69.27 $57.63 $64.01 $71.69 $79.63
Rates shown are per month per employee and are valid for a 12-month contract.
To enroll
Complete the Client Information Form and
return to Delta Dental along with enrollment
information, proof of prior dental coverage (if
applicable) and a check for the group’s first
month’s premium.
Submit to:
Delta Dental
Attn: Group Administration
PO Box 30416
Lansing, MI 48909
To download the Client Information Form,
visit the Producers section of our website
at www.deltadentalin.com.
Questions?
Call us today at (800) 382-5404 to learn
more about Delta Dental’s plans.
NOTE: Rates shown above are for clients with
effective dates between 10/1/12–9/30/13.
Participation
requirements
Number
eligible
Minimum
number insured
2 2
3 3
4 3
5 4
6 4
7 4
8 5
9 5
10–18 50%
NOTE: Immediate family members
must be enrolled together on
one application and count as one
eligible member.
At least 75 percent of the employees
must be physically located in the
state where the contract is held.
High-risk occupations
The following industry groups require the “high-risk occupation” rate adjustment:
Amusement/entertainment groups
(amusement parks, casinos, movie
theatres, pool halls)
Auto sales and service (new and used
auto sales, car washes, repair shops)
Bars/taverns
Construction firms/contractors
Garbage operations
Gas stations
Health/sport/country clubs
Hotels/motels
Insurance agencies
Janitorial services
Junk/scrap/salvage yards
Laundry/dry cleaning
Liquor stores
Movers/trucking operations
Nursing homes
Parking lot facilities
Pawn shops/used merchandise stores
Professional offices (doctors,
lawyers, architects)
Real estate agencies
Religious organizations
Restaurants
Security guard services
Studios (dance, theatrical
groups, photography)
Taxi/transportation services
The following industry groups are not eligible for coverage, however they may be
eligible for coverage through our individual product offerings. Contact your Delta Dental
sales representative for more information.
1099 contractors
Beauty/barber shops
Leased employees
Private households
Seasonal work (farming and
agricultural labor)
6122-IN v5 Rate Sheet
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