Delta Dental of Michigan

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Download an Agency/Agent Agreement Form:

 

 

Join the Team

Becoming a Delta Dental agent is quick and easy. To get started, determine whether you should sign the Agency/Agent agreement as an individual agent or as an agency.

 
If you’re an individual agent (not associated with an agency):
Please complete and sign the Agency/Agent agreement for the appropriate state (Michigan, Ohio, or Indiana), using your name, address, phone number, and fax number for commission payments. Please also include:
  1. A copy of your individual producer’s license
  2. A completed W-9
  3. Your Social Security number (required by the state)
If you’re signing the agreement on behalf of your agency:
First, check with Delta Dental to see if your agency already has an active agreement on file.
 
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.
 
Please also include:
  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)

Please fax all pages of the agreement to Delta Dental, Attn: Agent Services at (517) 347-5135.