Notice

Monday, May 25: Our offices will be closed in observance of Memorial Day. Warm wishes to you and your family as we honor and remember the brave men and women who sacrifice in service of our nation.


May 22 - September 4: Customer Service hours are Monday through Thursday 8:00 AM to 6:30 PM EDT and Friday 8:00 AM to 1:00 PM EDT.


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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