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

If you and/or your agency would like to be appointed to do business with Stryden, Inc. (Stryden) to sell DeltaVision®, please complete this form, include a copy of your Virginia Health Insurance License, and return to the address or fax number below. 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 Stryden.

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


Agent's Information
By providing my email address, I understand and authorize Delta Dental of Virginia (on behalf of Stryden, Inc.) to send all notices and communications to this address. Such notices include notice of non-renewal or cancellation, so it’s important to update us if your email changes. Contact Marketing Administration at mktgadmin@deltadentalva. com regarding these types of changes.
Enter numbers only, without dashes. For example: 5405555555.
Enter numbers only, without dashes. For example: 5405555555.
Agency Information
DeltaVision® is underwritten by Stryden, Inc., an affiliate of Delta Dental of Virginia. Claims processing, claims service and provider network administration for DeltaVision are provided by VSP.