Represent Delta Dental

Becoming a broker for Delta Dental of North Carolina is quick and easy! 

 

Are you an independent agent, or are you affiliated with an agency? Choose your category below.

Independent Agents

For individual agents (not associated with an agency): 

First, fill out the following form and fax it to us along with a copy of your current LA&H or A&H license. Please note, the Department of Insurance form is mandatory. Once we receive your documents, we will file them for you with the North Carolina Department of Insurance, and we’ll even pay your initial and renewal appointment fees, if applicable.

Please complete and sign the Broker Agreement below using your name, address, phone number, and fax number for commission payments.  As an independent agent, you do not have to complete the Agency Contact page. The following items must be included:

  1. A copy of your individual producer’s license 
  2. A completed W-9 
  3. Your Social Security number (required by the state)
  4. Direct Deposit Form and Deposit Slip or “Voided” Check
  5. North Carolina Department of Insurance Application for Individual Insurance License in Dental Services 

 

Please email all pages of the agreement to Delta Dental, Attn: Agent Services at specialservices@deltadentalmi.com.

Questions? Contact us at (800) 587-9514. 

Download Broker Agreement

In order to sell our individual product, the below document must also be completed.

Addendum to Sell Individual Product

If you're signing the agreement on behalf of your agency: 

If your agency has an active agreement with Delta Dental, a company officer will need to notify us in writing that you are an agent at this agency. Please provide your start date, a copy of your license, and your Social Security number. If your agency does not have an active agreement with Delta Dental, please have an officer (or another employee with the authority to bind the agency) sign the agreement. The agreement is with the agency rather than individual agents, which is why an authorized person must sign it.

Once we receive your documents, we will file them for you with the North Carolina Department of Insurance, and we'll even pay your initial and renewal appointment fees, if applicable. The following documents must be included:

  1. A copy of your agency’s license 
  2. A completed W-9 
  3. Copies of all the producers’ licenses
  4. All the producers’ Social Security numbers (required by the state)
  5. Direct Deposit Form and Deposit Slip or “Voided” Check
  6. North Carolina Department of Insurance Application for Individual Insurance License in Dental Services (Please note: The Department of Insurance form is mandatory and must be filled out for EACH producer)

 

Please email all pages of the agreement to Delta Dental, Attn: Agent Services at specialservices@deltadentalmi.com.

Questions? Contact us at (800) 587-9514.

Download Broker Agreement

In order to sell our individual product, the below document must also be completed.

Addendum to Sell Individual Product