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.
- Group Application - Eff. 1/1/2019
- EyeMed Group Application (Vision) - Eff. 5/1/2018
- Each eligible employee needs an
Employee Enrollment / Change Form.
Declination of Dental Coverage Form
- Waiving employees or dependents are not eligible for enrollment after initial enrollment unless qualifying event occurs if employer contribution is 100%.
Most recent quarter
quarterly wage statement reconciled.
A check for the first month’s premium made payable to “Delta Dental” or
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.
- BAA Business Associate Agreement for Group Health Plans must be submitted and signed by employer.
- Group contact’s email address.
If electing vision and you are not appointed with EyeMed, please include the following:
- Authorization for Electronic Deposit of Agent/Broker Commission 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.