Paper qualifying event form
Download and complete a paper form if you prefer, and mail it to PO Box 1157, Pierre, SD 57501, or fax it to 605-224-0909, or email it to eligibility@deltadentalsd.com.
Qualifying event form
Employer group administrators can use this form to notify us of a change in coverage status for an enrolled primary member or dependent.
Online form instructions:
- The entire form is displayed below.
- The form must be completed in one sitting. If you exit the page before submitting the form, your information will not be saved.
- Required responses are marked with an *
If you have any questions, contact us at eligibility@deltadentalsd.com or call 877-841-1478. We're happy to help!