Please use this checklist to ensure that all forms and information needed to process your group applications are included in the submission packet.

Delta Dental PPO□ Completed Enrollment forms – or Completed Enrollment List form.

• Completed Enrollment/Change form or Declination form for those not enrolling.□ Completed SBP group dental application.□ Completed EyeMed vision application, if applicable.□ Declination form.□ Current DE9C.

• If no DE9C available, payroll register will be acceptable.□ Business Associate Agreement – signature page only.□ Business check in the amount of the first month’s premium, payable to Delta Dental,

or initial premium authorization – first month’s premium only.□ If EyeMed Vision is being offered alongside Delta Dental – Agent/Broker has to be appointed. Pls. provide the

following: completed FSL Agent Data Sheet; completed Agent Data Sheet; copy of California agent and agency license; and copy of Errors & Omission Declaration Page.

DeltaCare□ Completed SBP group dental application.□ Completed EyeMed vision application, if applicable.□ Declination form.□ Completed DeltaCare application for each eligible employee or Declination form from those not enrolling – or

Completed Enrollment List form.□ Business Associate Agreement – signature page only.□ Business check in the amount of the first month’s premium, payable to Delta Dental.□ If EyeMed Vision is being offered alongside Delta Dental – Agent/Broker has to be appointed. Pls. provide the

following: completed FSL Agent Data Sheet; completed Agent Data Sheet; copy of California agent and agency license; and copy of Errors & Omission Declaration Page

Note: If enrolling both products (Delta Dental PPO and DeltaCare), then copies of both signature pages for the Business Associate Agreements must be submitted. List enrollment option is not available for DeltaCare.Mail all documents to:Claremont Insurance Services, 1000 Burnett Avenue, Suite 440, Concord, CA 94520.For assistance with open enrollment meetings and onsite application reviews, call us at 800.696.4543.

Delta Dental Small Group