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Delta Dental

Enrollment Kit - Delta Dental 

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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.  
Sold Group Process – Items to Submit:

  • Please include the proposal provided to you with indication of what plan(s) have been selected (Delta Dental PPO, DeltaCare USA DHMO & DeltaVision Plan Options)
  • Completed State Specific Employer Group Application:
  • Include Industry & SIC Code as quoted on proposal
  • Group can choose 3 or 4 tier rates and enter along with # enrolled in each tier – include rates for ALL appropriate Rate Tiers sold & Enrollment for ALL Tiers – if there is no enrollment in a specific tier – write in “0”
  • Calculate First Month’s Premium within the application – TOTAL will tally automatically
  • Be sure to fully complete the Broker information and signature/date and fully complete General Agent section and signature/date if applicable 
First Month’s Premium is due with Application:
  • Match TOTAL as calculated within the Employer Group Application
  • Payable via Check or ACH Payment ** If via ACH Payment, complete IPA (Initial Premium Authorization) **
  • If via Check, include copy of check with paperwork submission
  • Partial Premium Designation: This is required for partial payment designation when writing dental and vision 
 New Group List Enrollment Form:
  • List all eligible employees (enrolling or not) and indicate their status (i.e., waiving/enrolling). If waiving/not enrolling, provide reason why (i.e., other coverage or other reason). Note, spousal waivers count towards meeting participation
  • Be sure to complete ALL fields (i.e., employee SSN, DOB and Dates of Hire).

                                                                  After approval, prior carrier termination letter must be submitted by the employer or broker. 
After approval, prior carrier termination letter must be submitted by the employer or broker. Important Reminder: To help your client comply with ACA requirements, provide a copy of the appropriate Summary of Benefits and Coverage (SBC) to each employee at the Enrollment Meeting, via email or by posting on an internal company website