Current Location: Delta Dental Of Minnesota > Brokers > Forms & Publications

The following documents can only be viewed by using Acrobat® Reader® software, which can be downloaded free of charge from http://www.adobe.com/.

Group & Enrollment

• Dental Claim Form
• Membership Enrollment Form (excludes Dental Flex)
• Membership Enrollment Form - Spanish
• Dental Flex Enrollment Form
• Membership Maintenance Form (includes Dental Flex)
• Disabled Dependent/Michelle's Law Application
• International Emergency and Expatriate Dental Program Claim Form with Instructions for Members
• HIPAA Designated Contact Form
• Authorization to Release Information
• DDMN Capabilities Brochure
• COBRA Premium Subsidy
• COBRA Election Form for ARRA (this form is only for groups with less than 20 full-time employees)

Broker Forms

• Broker Administration Manual
• Agent of Record Assignment Form
• Group Master Application (Pooled)
• Group Master Application (Individually Rated)
• ACH Commission Form
• Online Commission Reports User Request Form
• Online Commission Reports Help
• Broker Commission Agreement

To request a benefit summary for groups of 5-199 employees, please e-mail deltadentalconnect@deltadentalmn.org.  Existing groups, please provide us with your group name or group number.  For new groups, please provide us with the product name, deductible, orthodontics type (traditional or orthodontic discount program, if applicable) and maximum.

Broker Appointment Forms

• Appointment Documents

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