Agent Appointment Application

This application is for brokers interested in applying to sell Delta Dental insurance.
To complete this application, be ready to provide the following information:

• Personal information, including SSN.
• Agency information, including Federal Tax ID and business licenses.
• Broker license information for both your resident state and the state you wish to be appointed in.
• Checking account information for Direct Deposit setup.

After you complete the application, you will be asked to e-sign several digital forms. Estimated time to complete the application is 20 minutes.

If you have previously applied to sell Delta Dental insurance in Nebraska and wish to update your appointments, do not use this form. Rather, contact us via email at DDNEBroker@DeltaDentalNE.org or through the phone at 1-855-648-1409.