Notice

June 19: Customer Service will be closed in observance of Juneteenth. Juneteenth commemorates the end of slavery in the United States on June 19, 1865. Not familiar with Juneteenth, learn more about Juneteenth.


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 pulling up forms on laptop

Small group forms for brokers


Small Business Program Group Dental and Vision Application (PDF, 8 pages, 741 KB)

Delta Dental NJ Enrollment Template (Excel Spreadsheet)

Enrollment/Change Form (Dental) (PDF, 1 page, 627kb)

Enrollment/Change Form (Vision) (PDF, 1 page, 378kb)


Individual Commissions Forms


Producer Appointment Forms (PDF, 26 pages, 789KB)
 
On-Exchange Amendment to Producer Agreement Form (pdf, 1 page, 103KB)


Standard Forms for Brokers


Authorization Form Granting Access to PHI  (PDF, 1 page, 52kb) 

Download forms and applications

Small Group Forms

Use these forms and applications for 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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