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!

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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.