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Maine Dental Association Health Plan Census Survey

As you may know, the Maine Dental Association is in the exploration phase of researching an association health plan. We appreciate your participation in this census survey as the data provided will assist us in obtaining quotes for health insurance. Participation in this survey does not guarantee participation in any plan or that a plan will ultimately be available. This effort is part of our due diligence to see what options might exist to try and create a more affordable option for our members and their families and employees.  Thank you for you participation. If you have any questions, please contact Angela Westhoff, MDA Executive Director at 207-622-7900.

  • Please include all employees (including the dentist) who work an average of 30 hours per week whether they participate in your current insurance plan or not.
  • If you offer health insurance to employees who work fewer than 30 hours such as using a 25 hour threshold for eligibility, then include all employees that work that minimum hour threshold.
  • Please indicate if each employee currently participates in your health plan, waives due to having coverage elsewhere, or waives and has no health coverage.
  • The form below can be utilized to enter this data, however, we can accept the data in other reports if more convenient.  Electronic documents are preferred.
If you need to submit multiple copies of this form to include more employees, please do so.
Please do not hit the back button or the refresh icon as it will clear all information in your form.
Please call with questions, 207-622-7900.

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