RESOURCE CENTER

Installation Forms
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12.14.2016
Census Enrollment (Excel)
To be used ONLY with new 2-99 enrolled business. This excel file can be used in place of Enrollment Forms. It must be specifically used and returned in Excel format.
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12.14.2016
Small Business HIPAA Addendum (PA-MD)
Delta branded form to be completed by employer for new 2-99 enrolled business. This form is a HIPAA agreement for groups located in PA and MD.
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10.30.2016
Small Business PA Group Application (2-99)
Delta branded installation form to be completed by employer for new 2-99 enrolled business sitused in Pennsylvania.
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10.30.2016
Small Business PPO Enrollment/Change Form (2-99)
Employee enrollment form to be completed by any employee looking to enroll into a group Delta dental PPO product. Form doubles as waiver.
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Small Business DHMO Enrollment/Change Form (2-99)
Employee enrollment form to be completed by any employee looking to enroll into a group Delta dental DHMO product. Form doubles as waiver.
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01.29.2013
Small Business - Sold Group Process
Delta branded checklist for Case Installation. Please provide all required paperwork for 2-99 enrolled size groups. Paperwork must be received by B&B prior to 20th of month. A prior carrier benefit summary, while not noted is required.
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01.29.2013
Small Business HIPAA Addendum (DE)
Delta branded form to be completed by employer for new 2-99 enrolled business. This form is a HIPAA agreement for groups located in DE.
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01.29.2013
Initial Premium Authorization Form
Delta branded form to be completed by employer for new 2-99 enrolled business. This form can replace the need for a business check and will be used to automatically withdraw the 1st month's premium.
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08.26.2011
Delta BOR letter
Sample of Broker of Record letter to be used for existing Delta SBA clients. No other version will be acceptable. If group is a direct Delta account and not SBA, we must enroll as new SBA business. BOR will not be honored.
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