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Enrollment Kit - Delta Dental PPO (Dental)

This checklist is provided as a guide. The carrier may require additional items and documentation. Please refer to the carrier's underwriting guidelines for a complete list of requirements. Please use the latest version of forms.
Our goal is to process your new group enrollment easily and efficiently in order to provide you and your client with a quick approval.  The following list outlines Delta Dental PPO’s case submission requirements.
  • Group Application - Eff. 1/1/2019
  • Each eligible employee needs an Employee Enrollmen​t / Change Form.
  • Employee Declination of Dental Coverage Form required.
  • Waiving employees or dependents are not eligible for enrollment after initial enrollment unless qualifying event occurs if employer contribution is 100%.
  • Most recent quarter DE-9C​ quarterly wage statement reconciled.
  • A check for the first month’s premium made payable to “Delta Dental” or ACH Form​.
  • Minimum of 5 eligible employees must be enrolling (for 2-4 offerings, minimum 2 employees).
  • Dual Choice is available for 10+ enrolling employees. There must be a minimum of 2 enrolled on one plan and a balance of 8 on the other (with less than 10 combined employees, 2-4 plans / rates apply with a minimum of 2 enrolled under each plan).
  • Dual Choice Voluntary is available for 10 enrolling employees. There must be a minimum of 5 enrolled on one plan and a balance of 5 on the other (for 2-4 offerings, there must be a minimum of 2 enrolled on one plan and a balance of 2 on the other).
  • Orthodontia available for 10 enrolling in PPO (25 if Voluntary).
  • Dependents are eligible up to age 26.
  • Group contact’s email address.
  • If electing vision and you are not appointed with VSP, please include the following:
  • ​Authorization for Electronic Deposit of Agent/Broker Co​mmission Payments​​

After approval, prior carrier termination letter must be submitted by the employer or broker.​
For other useful or older documents, please refer to the Forms database.