Delta Dental of Arizona requires contracting for all producers that have sold business through us for Group or Individual Insurance.
Complete the form below to begin the contracting process.
Additional documentation will follow, by e-mail, in a few days.
Select I Agree I agree to the terms and conditions set forth within this producer agreement, producer business associate agreement and W9.
Select I Agree 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 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.
Select I Agree 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.
Please enter the form authorization code in the text box below.