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Applicant Info









Are you using a General Agency?  

Select Your Dental Plan

You'll find a Dental Plan just right for you, you and one dependent, or you and your family. Choose from our Gold, Silver or Bronze plans.

Below you can enroll in our standard individual dental plans.

Plan Gold Silver Bronze
Single Single
Two-Person Two-Person
Family Family

Single coverage covers you only. Two Person coverage includes you and one qualified dependent. Family coverage includes you and multiple qualified dependents.

Your Membership Information

Tell us about you and your dependents (for Two-Person and Family memberships). Your personal information is confidential and our online enrollment process is secure. We do not share your personal or contact information with any outside parties. View our Privacy Policy

APPLICANT
* Indicates a required field.
*Desired Start Date:
Please note that the plan rates above are based on the selected desired start date.
Social Security Number:

*First Name:

Middle Initial:

*Last Name:

*Marital Status:

*Gender:

*Birth Date:
(mm/dd/yyyy)
*Employment Status:

*What is your occupation?:

*Address Line 1:

Address Line 2:

*City:

State:
*Zip Code:

*E-mail Address:

*Confirm E-mail Address:

*Phone Number:

Alternate Phone:

*Prior Coverage:
Has anyone within this plan been covered by Delta Dental of Illinois within the past 60 days?

How did you hear about our individual plans?

Delta Dental of Illinois is commited to providing our enrollees with the best products and services available. By completing this short questionnaire, you will help us develop new products that will best serve your needs and those of people like you.

Your responses to this form will not be linked to your name or your policy and will remain completely confidential. Delta Dental of Illinois is committed to your privacy and never allows third parties to use your personally identifiable information to market their products or services.

Thank you for your help.

*Indicates a required field.
How did you hear about Delta Dental's individual dental plan?* (check all that apply)

What is the highest level of education you have completed?:
What is your annual household income?:
Are you a military veteran?:
How many total people live in your household?:

How many of those people are under the age 18?:

What was your primary reason for buying this policy?:

How many other companies' policies did you consider before buying this one?:

How long did you spend reading about this policy, and about individual dental insurance policies in general, before buying this policy?:




Note: Online enrollment cannot be completed due to maintenance during the following times:
-Monday through Saturday: Midnight - 2 a.m. CST
-Sunday: Midnight - 7 a.m. CST