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Request for Quote

Use the form below to submit an online request for a quote.  Our staff will be in contact with you upon receipt of your completed form.   If you have any questions, or would like further information, contact Delta Dental of Wyoming at 307-632-3313, toll free at 1-800-735-3379 or via email at customerservice@deltadentalwy.org.

Employer Sponsored Plan Details 

Plan 

Coverage

Deductible

Employee Participation Requirements
10000 (No Ortho)
100/80/50
$50 per person/$100 Family
100% must be enrolled
Minimum of 5 employees
11000 (With Ortho)
100/80/50/50
$50 per person/$100 Family
100% must be enrolled
Minimum of 20 employees
30000 (No Ortho)
100/50/50
$50 per person/$100 Family
100% must ben enrolled
Minimum of 3 employees
31000 (With Ortho)
100/50/50/50
$50 per person/$100 Family
100% must be enrolled
Minimum of 20 employees
50000 (No Ortho)
80/80/50
$50 per person/$100 Family
100% must be enrolled
Minimum of 5 employees
51000 (With Ortho)
80/80/50/50
$50 per person/$100 Family
100% must be enrolled
Minimum of 20 employees
80800 (No Ortho)
100/50
$50 per person/$100 Family
100% must be enrolled
Minimum of 2 employees

Voluntary Plan Details 

Plan 

Coverage

Deductible

Employee Participation Requirements
Voluntary Plan (With Ortho)
100/75/50/50
$50 per person/$100 Family
50% must be enrolled
Minimum of 20 employees (unless currently have ortho coverage)
Voluntary Plan (No Ortho)
100/75/50
$50 per person/$100 Family
50% must be enrolled
Minimum of 5 employees

Individual Plan Details

Please visit our Individual Plans section for information 

Plan Design Requested
Employer Sponsored






Voluntary Plan

Section 1 - Broker/Agent Info (Not Required)
First Name
Last Name
Company
Title
Street Address
City
State
Zip
Phone
Fax
Email
Section 2 - Group Information
Group Name*
Address*
City
State*
Zip*
Phone Number*
Email Address
Section 3 - Census Information
Total Number of Employees*
Number of Single Employees*
Number of Employees Plus One*
Number of Families*
If the Group has prior coverage, please provide an outline or summary of coverage and rates if available