Delta Dental of Arizona   (Select your state)
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Contracting with Delta Dental

Delta Dental of Arizona requires contracting for all producers that have sold business through us for Group or Individual Insurance.

  1. Complete the form below to begin the contracting process.
  2. We will respond with your producer number within 48 hours. (Excluding holidays and weekends)
  3. Additional documentation will follow, by e-mail, in a few days.

To view or print document, click on the document name.

**Numbers Only
Business Information
  Select Category
  Name on AZ Department of
Insurance License
First Name, MI
Last Name

  Broker Title
  Business Name
  Business Address Street Number, Apt, Suite
  City
  Zip Code** 
  Business Telephone**
  Business Email
  Exempt From Backup Withholding (W9)
  Taxpayer Identification Number(s)** SSN
Tax ID
  AZ Dept of Insurance License Number** AZ License
  National Producer Number** NPN
 
Terms and Conditions
  I agree to the terms and conditions set forth within this producer agreement, producer business associate agreement and W9.

  Electronic Signature
  I certify that by selecting "I agree" from the box above that I am the applicant listed above and that this is my digital signature signifying my agreement to adhere to the above producer business agreement.

Direct Deposit

Direct Deposit of funds is a safe, easy and efficient way to transmit weekly deposits directly into your bank account. You have the option of receiving direct deposit notification either by mail or email.

If you have multiple offices and would like direct deposit to different accounts for each location, it is necessary to complete a form for each office location. Accuracy of information is essential.

  Name of Financial Institution
  Bank Phone Number**
  Bank Account Number** Account Number
Re-Enter Account Number
  Bank Routing Number** Enter Route
Re-Enter Route
  Authorized Principal & Title Principal & Title
 
 
  Account Type Checking Savings
(Delta Dental of Arizona will keep all financial information secure and confidential.)
 
    I (we) hereby authorize Delta Dental of Arizona, Inc. to initiate credit entries to my (our) indicated account at the financial institution named above.

By continuing, you agree that you are the participating broker and authorized signatory on the account. In addition, you ensure that the account information you have provided is correct. This includes the correct spelling, capitalization and punctuation of all of the information that you have provided.

This authority is to remain in full force and effective until Delta Dental of Arizona Inc. (DDAZ) and said financial institution have received written notification from me of its termination in such time and manner as to afford DDAZ and said financial institution reasonable opportunity to act on it.

Email of Business Contact to receive direct deposit notification Enter Email
Re-Enter Email


Please enter the form authorization code in the text box below.


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