Broker ADR Form

Agent/Agency Data Request Form

VERY IMPORTANT: Before completing the online form, please read below:

If you are with an agency who IS appointed, but you are NOT appointed, complete the online form by filling in the fields below.

If you are with an agency who is NOT appointed, complete the entire appointment packet by downloading: Appointment packet.

*Required

Agent's Information

Agent’s name (as licensed) *

Agent’s name (as licensed) is mandatory

Virginia License Number *

Virginia License Number is mandatory

Social Security Number *

Social Security Number is mandatory

Correspondence address *

Correspondence address is mandatory

City *

City is mandatory

State *

Please select at least one of the items

Zip *

Zip is mandatory

Individual email (no shared email addresses) *

Individual email (no shared email addresses) is mandatory

By providing my email address, I authorize Delta Dental of Virginia to send notices and communications to my email address. Email Marketing Administration at brokerhelp@deltadentalva.com when you have updates to your email address.

Business phone *

Business phone is mandatory

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

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

Yes

Please select at least one of the items

If yes, group name

If yes, group name is mandatory

Effective date

Effective date is mandatory

Agency Information

Agency name (as licensed)

Agency name (as licensed) is mandatory

Tax ID

Tax ID is mandatory

Virginia license number

Virginia license number is mandatory

Correspondence address

Correspondence address is mandatory