Represent Delta Dental as a Broker

If you're signing the agreement on behalf of your agency: 

If your agency has an active agreement with Delta Dental, a company officer will need to notify us in writing that you are an agent at this agency. Please provide your start date, a copy of your license, and your Social Security number. If your agency does not have an active agreement with Delta Dental, please have an officer (or another employee with the authority to bind the agency) sign the agreement. The agreement is with the agency rather than individual agents, which is why an authorized person must sign it.

Once we receive your documents, we will file them for you with the North Carolina Department of Insurance, and we'll even pay your initial and renewal appointment fees, if applicable. The following documents must be included:

1. A copy of your agency’s license 
2. A completed W-9 
3. Copies of all the producers’ licenses
4. All the producers’ Social Security numbers (required by the state)
5. Direct Deposit Form and Deposit Slip or “Voided” Check
6. North Carolina Department of Insurance Application for Individual Insurance License in Dental Services (Please note: The Department of Insurance form is mandatory and must be filled out for EACH producer)

Please email all pages of the agreement to your Delta Dental Representative for processing if applicable or email to specialservices@deltadentalmi.com if not currently working with a representative.

Questions? Contact us at (800) 587-9514.

In order to sell our individual product, the below document must also be completed.