Agent/Agency Data Request (ADR) Form

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