PESC Administrators

Requested effective date:
Eligibility waiting period for new hires: months(s)
(NOTE: Dental plan eligibility will begin on the first day of the month following the waiting period)
To whom does the eligibility waiting period apply:

Current Employees
People who will be eligible in the future

Is employee participation:

Non-Contributory (group pays 100% of enrolled employee’s cost)
Contributory; group pays % of employee’s cost and % of dependent’s cost

(NOTE: 75% of eligible employees must enroll in contributory plans)

Which categories of employees are eligible for dental benefits? (choose one or both)

Full-time employees defined as those who work more than hours per week
Part-time employees defined as those who work more than hours per week

Number of months employees are eligible to continue group coverage while on employer-approved:

temporary personal leave of absence: (maximum 3 months)
temporary medical leave of absence: (maximum 6 months)

Self Funding Rates:

This is a preliminary application.
All terms are negotiable until a contract is signed by poth parties.

Employee Only	$
Employee + Spouse	$
Employee + Children	$
Family	$

555 W. Shaw Ave., Suite C-1
Fresno, CA 93704

(866) 777-1320
(559) 256-1320
559.256.1321 fax