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DENTAL

___1. Will those covered visit a dentist at least twice next

year? 0-3 points……….coverage is not recommended

0 No 4 Yes ___2. Do those covered anticipate having major dental work in the next year? 0 No

5 points…………..flexible spending account is recommended 6-10 points……….premium plan is recommended

3 Yes

___3. Do those covered plan on having braces next year? 0 No

4 points………....standard plan is recommended

11 points…………..premium plan w/flexible spending account

3 Yes

__4. Are you comfortable using a flexible spending account? 0 No ___ Total

1 Yes

My recommendation is__________________

VISION

____2. Are those to be covered currently prescribed glasses or contacts? 0 No

4 Yes

____3. Do you anticipate those covered will be prescribed glasses or contacts within the next year? 0 No 4 Yes ____4. Does the person(s) covered always have an annual eye exam? 0 No

0-3 points……...coverage is not recommended 4-11 points……...coverage is recommended 12+ points ………flexible spending account is recommended

2 Yes

____5. Are the people being covered under this plan also under your Georgia Health Insurance Plan? 0 No

1 Yes

____6. Are you comfortable using a flexible spending account? 0 No

10 Yes

My recommendation is__________________

_____ Total

CRITICAL ILLNESS ____1. Do the people to be covered have health insurance? 0 No

1 Yes

____2. Do the people to be covered have disability insurance? 0 No

1 Yes

____4 Are you saving at least 10% of your income every month? 0 No

1 Yes

____5. Do the people to be covered have adequate life insurance? 0 No

1 Yes

0-4 points…….…...coverage is not recommended 5 points……………..coverage may be recommended

___6. Do the people to be covered have major concerns about experiencing a critical illness? 0 No

_____ Total

#

1 Yes

My recommendation is__________________

Models 2  
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