Broker ADR Form

Agent/Agency Data Request (ADR) Form for Dental Plans

If you and/or your agency would like to be appointed to do business with Delta Dental of Virginia, please complete this form and include a copy of your Virginia Health Insurance License. A form must be completed for each agent who wishes to be appointed. If commission is being paid directly to the agency, then also complete the agency section below.

You must hold a valid Virginia license to become appointed with Delta Dental of Virginia.

Prefer to mail or fax your form? Download a printable version.

*Required

Agent's Information

Agent's first name *

Agent's first name is mandatory

Agent's last name *

Agent's last name is mandatory

Virginia license number *

Virginia license number is mandatory

National producer number *

National producer number is mandatory

Social security number *

Social security number is mandatory

Date of birth *

Date of birth is mandatory

Agent's address *

Agent's address is mandatory

City *

City is mandatory

state *

Please select at least one of the items

Zip *

Zip is mandatory

Agent Email (no shared email addresses) *

Agent Email (no shared email addresses) is mandatory

By providing my email address, I understand and authorize Delta Dental of Virginia to send all notices and communications to this address. Such notices include notice of non-nenewal or cancellation, so it’s important to contact us at mktgadmin@deltadentalva.com if your email changes.

Phone *

Phone is mandatory

Enter numbers only, without dashes. For example: 5405555555.

Fax

Fax is mandatory

Enter numbers only, without dashes. For example: 5405555555.

Will you be selling group or individual business? (Check all that apply.) *

Group

Individual

Please select at least one of the items

Do you currently have a group application pending with Delta Dental of Virginia? *

Yes

Please select at least one of the items

If yes, what is the group's name?

If yes, what is the group's name? is mandatory

What is the effective date of the pending group application?

What is the effective date of the pending group application? is mandatory

Would you like commission to be payable to the agent or agency? (If agency, complete the agent section below.) *

Agent

Agency

Please select at least one of the items

Agency Information

Agency name

Agency name is mandatory

Tax ID

Tax ID is mandatory

Virginia license number

Virginia license number is mandatory

National producer number

National producer number is mandatory

Agency address

Agency address is mandatory

City

City is mandatory

State

Please select at least one of the items

Zip

Zip is mandatory