Notice

Friday, April 3: Our Customer Service Center will be closed in observance of Good Friday. 
Friday, April 10: Our Customer Service Center will only be available from 10:00 AM to 5:00 PM, due to staff development. 

To view benefit information and claim status at any time, you can sign into your account or use our Interactive Voice Response System 24/7 at (800-452-9310).

Dental Forms for Brokers

Find a variety of helpful forms or applications to keep your client’s information updated.
woman working on laptop

Small group forms for brokers


Small Business Program Group Dental and Vision Application (PDF, 8 pages, 733 KB)

Delta Dental CT Enrollment Template (Excel Spreadsheet)

Enrollment/Change Form (Dental and Vision) (PDF, 1 page, 204kb)


Individual Commissions Forms


Producer Appointment Forms (PDF, 26 pages, 789KB)


Standard Forms for Brokers


Authorization Form Granting Access to PHI - Insured Clients (PDF, 3 pages, 52kb)

Authorization Form Granting Access to PHI - Self Funded Clients (PDF, 3 pages, 51kb)

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Small Group Forms

Use these forms and applications for your small groups

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Individual Commissions Forms

Get started on becoming an individual and family plan broker

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Standard Forms

Keep client information up to date

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