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.