Enroll Now!
If you'd like to enroll online today, please complete the application below.
The effective date of your plan will be the first of the month following receipt of your completed enrollment form and payment or payment authorization. Enrollment forms MUST be received by the last working day of the month.
Payment Options include:
Option 1: Check - Annual Premium (Please mail your check into Delta Dental of Wyoming right away for coverage to be effective)
Option 2: Electronic Funds Transfer (EFT) - Monthly Premium
If you'd like to download, print & mail in your enrollment form please click the following link.
Delta Dental Individual & Family Plan Application
The effective date of your plan will be the first of the month following receipt of your completed enrollment form and payment or payment authorization. Enrollment forms must be received by the last working day of the month. The initial term of your policy will be for one year from the effective date. After the initial term, this policy will renew automatically establishing a new effective date each year until a change is submitted or until this agreement is terminated. This policy may be terminated upon thirty (30) days notice to Delta Dental of Wyoming.
Delta Dental of Wyoming reserves the right to change premium rates upon renewal of the policy. Notice of rate changes and/or plan modifications will be provided at least 45 days before the effective date. Delta Dental agrees to keep your coverage in force as long as you continue to pay the premiums on time and as long as you retain residency in the state of Wyoming.
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