Benefits
Name: 


  1. Please help us understand what description best fits your situation:
    I need medical only
    I need dental only
    I need both medical and dental
    I need medical and would like dental but do not need it
    I need dental and would like medical but do not need it
    I do not need these benefits at this time


  1. Would you have dependents to include?
    Yes
    No


  1. Name and Age of Yourself


  1. Name(s) and Age(s) of Your Dependent(s)


  1. How much would you want to pay out of each check for your benefits? (Answer the maximum you would want to pay)
    $50-$99
    $100-$149
    $150-$199
    $200-$249
    $250-$299
    $300-349
    $350+





ARC Smart
AZ