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The Boston Mutual Independence Voluntary Dental Plan

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Boston Mutual Agent Application

Benefits

Voluntary Group Dental Insurance
For Groups of Two or more
No Participation Requirements
Clients can Choose any Dentist
Optional 24-month rate guarantee
Takeover benefits for groups of 5 or more

Choose any Dentist!
100% Usual, Reasonable, and Customary Benefits No Deductible	TYPE I – PREVENTIVE SERVICES Periodic Oral Exams, Prophylaxis, Fluoride Treatment, Sealants, Space Maintainers and Harmful Habit Appliances
80% Usual, Reasonable, and Customary Benefits 6 Month Waiting Period	TYPE II – BASIC SERVICES X-Rays, Fillings, Simple Extractions and Palliative Treatment
50% Usual, Reasonable, and Customary Benefits 12 Month Waiting Period	TYPE IIIA – MAJOR SERVICES Endodontics, Periodontics (Treatment of Gum Disease) including Periodontal Cleanings, Oral Surgery (other than simple extractions), Recementation of Crowns and Bridges and Denture Repairs
50% Usual, Reasonable, and Customary Benefits 24 Month Waiting Period	TYPE IIIB - MAJOR PROSTHETIC SERVICES Inlays, Onlays, Crowns (including stainless steel and resin crowns), Dentures and Bridges
$50.00 Per Year Per Family Member	Annual deductible applies only to: TYPE II – BASIC SERVICES TYPE IIIA – MAJOR SERVICES AND TYPE IIIB – BASIC PROSTHETIC SERVICES
$1,000	POLICY YEAR MAXIMUM – Per person per policy year. Applies to all types of services.

Terms: Sole proprietorships, partnerships, or corporations with at least one (2) full-time employee, including active, full-time owners or partners, are eligible.

Employees: All active, full-time employees working at least 20 hours per week, including active, full-time owners or partners are eligible. Those employed on the date the firm becomes insured are eligible on that date. New employees hired after that date are eligible after a waiting period selected by the employer.

Dependents: Eligible dependents include the insured employee’s spouse and unmarried children prior to their 19th birthday who do not work for the firm. In addition, unmarried children from their 19th birthday to the day before their 24th birthday are eligible if they are primarily dependent upon the employee for more than 50% of their support and maintenance and are listed as dependents on the employee’s Federal tax return.

Usual, Reasonable, and Customary Benefits: Benefits are based on the Usual and Customary fee, as determined by Gerber Life, in the area in which the Dentist practices.

Boston Mutual Brochure and Application

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