Implementation Forms
Delta Dental has provided all the materials that you need online to purchase and install a small group plan.
Master Application 2-9
Enrollment Form-English
Enrollment Form-Spanish
BMT Authorization Form – small groups under 100
Automatic Draft / ACH Authorization Form
A copy of the Unemployment Insurance Report of Worker Wages must also be submitted.
Proposal
You can download our 2-9 proposal which includes plan designs, rates and underwriting guidelines,
as well as all of the necessary forms to sign up for group coverage.
|
|
What Next?
If you would like to purchase one of Delta Dental's Small group options, please print and complete the
Master Application, Enrollment Forms*, BMT Authorization form, ACH Authorization form, estimated 1st month premium,
and Producer Fee Agreement. Send to:
Delta Dental of Colorado
Attn: Small Group Sales
4582 S. Ulster Street, Suite # 800
Denver, CO 80237
Or you can email the information to
SmallGroupSales.under100@ddpco.com
If your application and enrollment forms are received before the 20th of the month,
your group will be eligible the first of the next month. You will be sent a welcome letter once your application and enrollment forms
have been processed.
*Enrollment forms must be completed for all eligible employees enrolling in the plan and initial time of enrollment.
|
